Provider Demographics
NPI:1356686604
Name:REDWELL & WIETIES EYECARE
Entity Type:Organization
Organization Name:REDWELL & WIETIES EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER / OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:BEDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-544-3525
Mailing Address - Street 1:P.O. BOX 658
Mailing Address - Street 2:905 W. MEFFORD ST.
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1065
Mailing Address - Country:US
Mailing Address - Phone:618-544-3525
Mailing Address - Fax:618-544-3261
Practice Address - Street 1:905 W MEFFORD ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1065
Practice Address - Country:US
Practice Address - Phone:618-544-3525
Practice Address - Fax:618-544-3261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007815152W00000X
IL046-008222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIETIES P01082010OtherPALMETTO GBA
ILWIETIES 046-008222Medicaid
BEDWELL 0790230001OtherPALMETTO GBA
ILBEDWELL 046-007815Medicaid
WIETIES 76409001Medicare PIN
BEDWELL 764090Medicare PIN
WIETIES P01082010OtherPALMETTO GBA
ILBEDWELL 046-007815Medicaid
0790230001Medicare NSC