MEDICARE: MARION PEDIATRIC CLINIC SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036103701	IL

General Provider Information

NPI Number	:	1154642411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARION PEDIATRIC CLINIC SC

Provider Business Mailing Address
First Line	:	3331 W DEYOUNG ST STE 207
Second Line	:
City	:	MARION
State	:	IL
Zip	:	62959-5897
Country	:	US
Telephone Number	:	618-993-5274
Fax Number	:	618-993-0639

Provider Business Practice Location Address
First Line	:	3331 W DEYOUNG ST STE 207
Second Line	:
City	:	MARION
State	:	IL
Zip	:	62959-5897
Country	:	US
Telephone Number	:	618-993-5274
Fax Number	:	618-993-0639

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LUIS A LOPEZ
Credential	:	MD
Telephone Number	:	618-993-5274

Provider Enumeration Date	:	06/21/2010
Last Update Date	:	06/21/2010

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