Healthcare Provider Details

I. General information

NPI: 1629217179
Provider Name (Legal Business Name): MT. VERNON OB-GYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 MCPHERSON AVENUE
MT. VERNON IL
62864
US

IV. Provider business mailing address

3408 OFFICE PARK DRIVE
MARION IL
62959
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5266
  • Fax: 618-997-5285
Mailing address:
  • Phone: 618-997-5266
  • Fax: 618-997-5285

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: MICHAEL J. SCHIFANO
Title or Position: OWNER/PRESIDENT
Credential: D.O.
Phone: 618-997-5266