1689601940 NPI number — RETINA CONSULTANTS OF CENTRAL ILLINOIS, SC

Table of Contents

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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