Basic Information
| Provider Information | |||||||||
| NPI: | 1598095036 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARION VAMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975311 | ||||||||
| FaxNumber: | 6189934194 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975311 | ||||||||
| FaxNumber: | 6189934194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2010 | ||||||||
| LastUpdateDate: | 01/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | MATHIS | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | COMMUNITY CARE CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6789975311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.S.W. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 150012269 | IL | Y | Hospitals | Military Hospital |
No ID Information.