Basic Information
| Provider Information | |||||||||
| NPI: | 1831840180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYVILLE IMAGING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOSHEN IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 STATE ROUTE 162 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182884929 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3417 ANDERSON HEALTHCARE DR | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620257784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182884929 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2022 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ENGELKE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | DALE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6186354242 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARYVILLE IMAGING, LLC | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.