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General NPI Number Information
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NPI Number | 1205372778
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Entity Type | Organization
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Legal Business Name | CHESI MARION CENTRE CLINIC
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Dates
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Enumeration Date | 01/09/2017
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Last Update Date | 01/09/2017
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Provider Practice Location Address
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Address Line | 3111 WILLIAMSON COUNTY PKWY OFFICE A3
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City | MARION
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State | IL
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Zip | 62959-5235
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Country | US
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Telephone | 618-734-4400
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Fax |
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Provider Business Mailing Address
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Address Line | 1250 CEDAR CT
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City | CARBONDALE
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State | IL
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Zip | 62901-5334
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Country | US
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Telephone | 618-457-0450
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | FRED BERNSTEIN
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Credential |
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Telephone | 618-457-0450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | IL
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