Provider Demographics
NPI:1093854820
Name:CENTER FOR SIGHT OF CENTRAL ILLINOIS SC
Entity Type:Organization
Organization Name:CENTER FOR SIGHT OF CENTRAL ILLINOIS SC
Other - Org Name:CENTRAL ILLINOIS VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:S
Authorized Official - Last Name:DERANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-233-3101
Mailing Address - Street 1:2442 N ROUTE 121
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-9461
Mailing Address - Country:US
Mailing Address - Phone:217-233-3101
Mailing Address - Fax:217-233-3107
Practice Address - Street 1:2442 N ROUTE 121
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9461
Practice Address - Country:US
Practice Address - Phone:217-233-3101
Practice Address - Fax:217-233-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009767152W00000X
IL036069820152WC0802X, 207W00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069820Medicaid
IL180033361OtherRAILROAD MEDICARE
IL05822331OtherBLUE CROSS
IL5506460001Medicare NSC
IL212322Medicare PIN
ILDE5448Medicare Oscar/Certification
IL216059Medicare PIN
IL05822331OtherBLUE CROSS
IL704100Medicare PIN