Provider Demographics
NPI:1396201836
Name:MID-STATE EYE PARTNERS INC
Entity Type:Organization
Organization Name:MID-STATE EYE PARTNERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-935-9451
Mailing Address - Street 1:102 N HEINLEIN DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565-9050
Mailing Address - Country:US
Mailing Address - Phone:217-774-4422
Mailing Address - Fax:
Practice Address - Street 1:125 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-1611
Practice Address - Country:US
Practice Address - Phone:217-935-9451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty