Provider Demographics
NPI:1033353644
Name:GAILEY EYE CLINIC, LTD
Entity Type:Organization
Organization Name:GAILEY EYE CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-829-5311
Mailing Address - Street 1:2435 VILLAGE GREEN PL
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7676
Mailing Address - Country:US
Mailing Address - Phone:217-398-1700
Mailing Address - Fax:217-398-3700
Practice Address - Street 1:2435 VILLAGE GREEN PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7676
Practice Address - Country:US
Practice Address - Phone:217-398-1700
Practice Address - Fax:217-398-3700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL616310Medicare PIN