1437193554 NPI number — EIGENBRODT VISION CENTER, P.C.

Table of content: (NPI 1437193554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437193554 NPI number — EIGENBRODT VISION CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EIGENBRODT VISION CENTER, P.C.
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:
1437193554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 EDWARDSVILLE CLUB PLAZA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDWARDSVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62025-3717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-656-3199
Provider Business Mailing Address Fax Number:
618-656-3099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 EDWARDSVILLE CLUB PLAZA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDWARDSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62025-3717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-656-3199
Provider Business Practice Location Address Fax Number:
618-656-3099
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EIGENBRODT
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-656-3199

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046008144 , 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)

  • Identifier: 274260 . This is a "GHP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DG3297 . This is a "PALMETTOGBA/RROADMED." identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5932266 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 400311 . This is a "GROUP HEALTH PLAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 901900 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 125419 . This is a "BLUE CROSS BLUE SHIELD MO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 125215 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 06032220 . This is a "BLUE CROSS BLUE SHIELD IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 115544 . This is a "EYEMED" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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