Basic Information
| Provider Information | |||||||||
| NPI: | 1215037890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARVEY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | AMAL KHOURY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172356055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 116 W BUCHANAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619202522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173457700 | ||||||||
| FaxNumber: | 2173457200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 12/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036-087846 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036087846 | 05 | IL | MEDICAID |