Basic Information
| Provider Information | |||||||||
| NPI: | 1629217179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MT. VERNON OB-GYN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3408 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975266 | ||||||||
| FaxNumber: | 6189975285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 MCPHERSON AVENUE | ||||||||
| Address2: | |||||||||
| City: | MT. VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975266 | ||||||||
| FaxNumber: | 6189975285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2009 | ||||||||
| LastUpdateDate: | 01/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | SCHIFANO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6189975266 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.