Basic Information
Provider Information | |||||||||
NPI: | 1073628129 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEINERS | ||||||||
FirstName: | MARSHA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RIDER | ||||||||
OtherFirstName: | MARSHA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | P O BOX 577 | ||||||||
Address2: |   | ||||||||
City: | CARTERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 629180577 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189858221 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1700 WILDCAT DR | ||||||||
Address2: |   | ||||||||
City: | MARION | ||||||||
State: | IL | ||||||||
PostalCode: | 629591506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189698228 | ||||||||
FaxNumber: | 6189980880 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 04/05/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-000677 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 101081 | 01 | IL | HEALTH ALLIANCE | OTHER | 370966854023 | 05 | IL |   | MEDICAID | 640701 | 01 | IL | PTAN MEDICAARE | OTHER | CF3444 | 01 | IL | MEDICARE RR | OTHER | 370966854014 | 05 | IL |   | MEDICAID |