Provider Demographics
NPI:1447222864
Name:PRAIRIE EYE CENTER, LTD
Entity Type:Organization
Organization Name:PRAIRIE EYE CENTER, LTD
Other - Org Name:PRAIRIE EYE & LASIK CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-698-3030
Mailing Address - Street 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4174
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-4728
Practice Address - Street 1:2020 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4174
Practice Address - Country:US
Practice Address - Phone:217-698-3030
Practice Address - Fax:217-698-4728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-000760152W00000X
207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC12503OtherRAILROAD MEDICARE
IL08400213OtherBCBS - MD
IL08432153OtherBCBS - OD
IL777490Medicare PIN
IL08400213OtherBCBS - MD
IN0364520001Medicare NSC