Provider Demographics
NPI:1033264791
Name:SOUTHERN ILLINOIS EYE CARE, PC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS EYE CARE, PC
Other - Org Name:MARISSA EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCHHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-826-4521
Mailing Address - Street 1:521 N BORDERS AVE
Mailing Address - Street 2:
Mailing Address - City:MARISSA
Mailing Address - State:IL
Mailing Address - Zip Code:62257-1117
Mailing Address - Country:US
Mailing Address - Phone:618-295-1600
Mailing Address - Fax:
Practice Address - Street 1:521 N BORDERS AVE
Practice Address - Street 2:
Practice Address - City:MARISSA
Practice Address - State:IL
Practice Address - Zip Code:62257-1117
Practice Address - Country:US
Practice Address - Phone:618-295-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL707420Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #