NPIMap

Organization Active NPI

Maryville Radiology Group, LTD

  • Diagnostic Radiology Physician
  • Maryville, IL
National Provider Identifier
1497773063
Registry record updated Feb 12, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
MARYVILLE RADIOLOGY GROUP, LTD
Practice address
Illinois Route 162
Anderson Hospital Dept of Radiology
Maryville, IL 62062
Phone
(618) 288-5711
NPI assigned
Jul 18, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 12, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Terry Burk, MDNPI 1124062757
Title
President
Phone
(618) 288-5711

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2085R0202X Primary

Addresses

Primary practice location

Illinois Route 162
Anderson Hospital Dept of Radiology
Maryville, IL 62062

Mailing address

PO Box 78130
Saint Louis, MO 63178-8130
Phone (309) 363-4660

Other identifiers 3

IdentifierTypeStateIssuer
149856OtherMOBCBS
6010052OtherILBCBS
99693OtherGHP

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL, NM, DC, TX, MO5 enrollments

Enrollment records 5

Enrollment IDStateProvider typePAC IDDetails
O20060411000165 IL Part B Supplier - Clinic/Group Practice 6608885256 Receives reassigned benefits from 5 practitioners
Practice locations: Maryville, IL; Staunton, IL
O20220324001513 NM Part B Supplier - Clinic/Group Practice 6608885256 Receives reassigned benefits from 1 practitioner
Practice locations: Los Ranchos, NM
O20221128000308 DC Part B Supplier - Clinic/Group Practice 6608885256 Receives reassigned benefits from 1 practitioner
Practice locations: Rockville, MD
O20241101000585 TX Part B Supplier - Clinic/Group Practice 6608885256 Receives reassigned benefits from 1 practitioner
Practice locations: Houston, TX
O20241211001454 MO Part B Supplier - Clinic/Group Practice 6608885256 Receives reassigned benefits from 1 practitioner
Practice locations: Columbia, MO

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153180800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1581465600000",
    "number": "1497773063",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 78130",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631788130",
            "telephone_number": "309-363-4660"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "ILLINOIS ROUTE 162",
            "address_2": "ANDERSON HOSPITAL DEPT OF RADIOLOGY",
            "city": "MARYVILLE",
            "state": "IL",
            "postal_code": "62062",
            "telephone_number": "618-288-5711"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARYVILLE RADIOLOGY GROUP, LTD",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-18",
        "last_updated": "2020-02-12",
        "certification_date": "2020-02-12",
        "status": "A",
        "authorized_official_last_name": "BURK",
        "authorized_official_first_name": "TERRY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "618-288-5711",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "149856",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "6010052",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GHP",
            "identifier": "99693",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Maryville, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 12, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.