MEDICARE: MARION EYE SURGERY CENTER LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	7003143	IL

General Provider Information

NPI Number	:	1295156669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARION EYE SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	2900 BROADWAY ST
Second Line	:	SUITE B
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2341
Country	:	US
Telephone Number	:	618-969-8700
Fax Number	:	618-899-9020

Provider Business Practice Location Address
First Line	:	2900 BROADWAY ST
Second Line	:	SUITE B
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2341
Country	:	US
Telephone Number	:	618-969-8700
Fax Number	:	618-899-9020

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MAQBOOL AHMAD
Credential	:	M.D.
Telephone Number	:	618-993-5686

Provider Enumeration Date	:	01/02/2014
Last Update Date	:	01/02/2014

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