1689601940 NPI number — RETINA CONSULTANTS OF CENTRAL ILLINOIS, SC

Table of content: (NPI 1689601940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689601940 NPI number — RETINA CONSULTANTS OF CENTRAL ILLINOIS, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA CONSULTANTS OF CENTRAL ILLINOIS, SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689601940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1466
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53008-1466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-788-9229
Provider Business Mailing Address Fax Number:
262-788-9241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3310 WEST CHARTWELL ROAD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-693-2249
Provider Business Practice Location Address Fax Number:
309-693-2583
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REDDY
Authorized Official First Name:
CHITTARANJAN
Authorized Official Middle Name:
V.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
309-693-2249

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  036090651 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 042-616854 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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