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General NPI Number Information
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NPI Number | 1386641066
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Entity Type | Organization
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Legal Business Name | EYE SURGERY CENTER OF MARYVILLE LLC
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Dates
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Enumeration Date | 07/07/2005
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Last Update Date | 04/11/2024
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Provider Practice Location Address
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Address Line | 12 PROFESSIONAL PARK DR
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City | MARYVILLE
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State | IL
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Zip | 62062-5672
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Country | US
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Telephone | 618-288-7483
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Fax | 618-288-4583
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Provider Business Mailing Address
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Address Line | 12 PROFESSIONAL PARK DR
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City | MARYVILLE
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State | IL
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Zip | 62062-5672
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Country | US
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Telephone | 618-288-7483
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Fax | 618-288-7196
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Authorized Official
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Title or Position | VP, CMO
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Name | JOSEPH PRAVOOT GIRA
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Credential | MD
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Telephone | 314-909-0633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 7002132
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License Number State | IL
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