NPIMap

Organization Active NPI

Maryville Imaging, LLC

  • Radiology Clinic/Center
  • Maryville, IL
National Provider Identifier
1912293002
Registry record updated Jun 8, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Radiology Clinic/CenterTaxonomy code 261QR0200X
Legal business name
MARYVILLE IMAGING, LLC
Practice address
2023 Vadalabene Dr
Suite 100
Maryville, IL 62062-5630
Phone
(618) 288-4929
Fax
(618) 288-4531
NPI assigned
Jun 27, 2011
Last updated
Jun 8, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 8, 2022

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

Authorized official

Name
Mr. Keith A. Page, FACH
Title
President
Phone
(618) 391-6406

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Radiology Clinic/Center 261QR0200X NU Primary

Addresses

Primary practice location

2023 Vadalabene Dr
Suite 100
Maryville, IL 62062-5630

Mailing address

6810 State Route 162
Box 215
Maryville, IL 62062-8501
Phone (618) 288-5711

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120327000046 IL Part B Supplier - Independent Diagnostic Testing Facility (Idtf) 3971763186 Practice locations: Maryville, IL

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

6810 State Route 162
Ste 215
Maryville, IL 62062
Phone (618) 391-6405

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 47

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 47

NPI Registry JSON

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

{
    "created_epoch": "1309132800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1654646400000",
    "number": "1912293002",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6810 STATE ROUTE 162",
            "address_2": "BOX 215",
            "city": "MARYVILLE",
            "state": "IL",
            "postal_code": "620628501",
            "telephone_number": "618-288-5711",
            "fax_number": "618-288-4088"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2023 VADALABENE DR",
            "address_2": "SUITE 100",
            "city": "MARYVILLE",
            "state": "IL",
            "postal_code": "620625630",
            "telephone_number": "618-288-4929",
            "fax_number": "618-288-4531"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARYVILLE IMAGING, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-06-27",
        "last_updated": "2022-06-08",
        "certification_date": "2022-06-08",
        "status": "A",
        "authorized_official_last_name": "PAGE",
        "authorized_official_first_name": "KEITH",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "618-391-6406",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "FACH"
    },
    "taxonomies": [
        {
            "code": "261QR0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "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 Jun 8, 2022; 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.