Healthcare Provider Details

I. General information

NPI: 1356857171
Provider Name (Legal Business Name): MARYVILLE WOMENS CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4972 STATE ROUTE 159
GLEN CARBON IL
62034
US

IV. Provider business mailing address

4972 STATE ROUTE 159
GLEN CARBON IL
62034
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-2970
  • Fax: 618-288-3572
Mailing address:
  • Phone: 618-288-2970
  • Fax: 618-288-3572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: LORI BEER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 618-288-2970