Healthcare Provider Details

I. General information

NPI: 1881623577
Provider Name (Legal Business Name): VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

2401 W MAIN ST
MARION IL
62959-1188
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax: 618-998-5661
Mailing address:
  • Phone: 618-997-5311
  • Fax: 618-998-5661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number4301040401
License Number StateIL

VIII. Authorized Official

Name: DR. MOHAMMED Y MANSURI
Title or Position: STAFFCARDIOLOGIST
Credential: MD
Phone: 618-997-5311