Provider Demographics
NPI:1730230848
Name:MARYVILLE INTERNAL MEDICINE, LTD
Entity type:Organization
Organization Name:MARYVILLE INTERNAL MEDICINE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-2120
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-288-2120
Mailing Address - Fax:618-288-2123
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 205
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-2120
Practice Address - Fax:618-288-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID NUMBER
IL211759Medicare ID - Type Unspecified