Provider Demographics
NPI:1376711283
Name:C E MYERS MD
Entity Type:Organization
Organization Name:C E MYERS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-693-2710
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-693-2710
Mailing Address - Fax:309-693-9460
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-693-2710
Practice Address - Fax:309-693-9460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36060306207W00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180001153Medicare PIN
IL0281450001Medicare NSC