Healthcare Provider Details

I. General information

NPI: 1124022785
Provider Name (Legal Business Name): COUNTY OF MARION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 CROSS CREEK BLVD
SALEM IL
62881-1920
US

IV. Provider business mailing address

118 CROSS CREEK BLVD
SALEM IL
62881-1920
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-3878
  • Fax: 618-548-9872
Mailing address:
  • Phone: 618-548-3878
  • Fax: 618-548-9872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. LORI RYAN
Title or Position: ADMINISTRATOR
Credential: RN,BSN
Phone: 618-548-3878