Healthcare Provider Details

I. General information

NPI: 1386641066
Provider Name (Legal Business Name): EYE SURGERY CENTER OF MARYVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PROFESSIONAL PARK DR
MARYVILLE IL
62062-5672
US

IV. Provider business mailing address

12 PROFESSIONAL PARK DR
MARYVILLE IL
62062-5672
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-7483
  • Fax: 618-288-4583
Mailing address:
  • Phone: 618-288-7483
  • Fax: 618-288-7196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7002132
License Number StateIL

VIII. Authorized Official

Name: JOSEPH PRAVOOT GIRA
Title or Position: VP, CMO
Credential: MD
Phone: 314-909-0633