Provider Demographics
NPI:1205829389
Name:HEYDE EYE CENTER S.C
Entity Type:Organization
Organization Name:HEYDE EYE CENTER S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:R
Authorized Official - Last Name:HEYDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-674-2244
Mailing Address - Street 1:400 NE SAINT MARK CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3717
Mailing Address - Country:US
Mailing Address - Phone:309-674-1234
Mailing Address - Fax:309-674-6422
Practice Address - Street 1:400 NE SAINT MARK CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3717
Practice Address - Country:US
Practice Address - Phone:309-674-1234
Practice Address - Fax:309-674-6422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207W00000X
IL036075507332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL322480Medicare PIN
IL0558410001Medicare NSC