Basic Information
| Provider Information | |||||||||
| NPI: | 1912293002 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYVILLE IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6810 STATE ROUTE 162 | ||||||||
| Address2: | BOX 215 | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182885711 | ||||||||
| FaxNumber: | 6182884088 | ||||||||
| Practice Location | |||||||||
| Address1: | 2023 VADALABENE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182884929 | ||||||||
| FaxNumber: | 6182884531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | PAGE | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6183916406 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | FACH | ||||||||
| NPICertificationDate: | 06/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.