Basic Information
| Provider Information | |||||||||
| NPI: | 1447203971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRLY | ||||||||
| FirstName: | HARVEY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 MEMORIAL DR | ||||||||
| Address2: | STE. 340 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182349884 | ||||||||
| FaxNumber: | 6182359020 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 MEMORIAL DR | ||||||||
| Address2: | STE. 340 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182357065 | ||||||||
| FaxNumber: | 6182359020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 036085921 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1447203971 | 05 | IL | MEDICAID | 6394100002 | 01 | IL | MEDICARE DME | OTHER |