MEDICARE: DR. HARVEY LEE MIRLY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0106X	Orthopaedic Hand Surgery Physician	036085921	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	6394100002	OTHER	IL	MEDICARE DME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447203971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HARVEY LEE MIRLY M.D.

Provider Business Mailing Address
First Line	:	4700 MEMORIAL DR
Second Line	:	STE. 340
City	:	BELLEVILLE
State	:	IL
Zip	:	62226-5373
Country	:	US
Telephone Number	:	618-234-9884
Fax Number	:	618-235-9020

Provider Business Practice Location Address
First Line	:	4700 MEMORIAL DR
Second Line	:	STE. 340
City	:	BELLEVILLE
State	:	IL
Zip	:	62226-5373
Country	:	US
Telephone Number	:	618-235-7065
Fax Number	:	618-235-9020

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	02/11/2021

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