Basic Information
| Provider Information | |||||||||
| NPI: | 1467409599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCINCZYK | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1125 | ||||||||
| Address2: | |||||||||
| City: | MARYLAND HEIGHTS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630430125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887311036 | ||||||||
| FaxNumber: | 4238925838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184637311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 2005024595 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 036.095452 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 203133 | 01 | MO | BCBS | OTHER | 036095452 | 05 | IL | MEDICAID | 207562307 | 05 | MO | MEDICAID | P00316808 | 01 | RR MEDICARE | OTHER |