Provider Demographics
NPI:1497996748
Name:MR. JOSEPH T MARCIN, JR
Entity Type:Organization
Organization Name:MR. JOSEPH T MARCIN, JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MARCIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:217-562-2432
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-0230
Mailing Address - Country:US
Mailing Address - Phone:217-562-2432
Mailing Address - Fax:217-562-2446
Practice Address - Street 1:120 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1430
Practice Address - Country:US
Practice Address - Phone:217-562-2432
Practice Address - Fax:217-562-2446
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MR. JOSEPH T. MARCIN, JR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-17
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410006290OtherRAILROAD MEDICARE/PALMETTO GBA
IL0735740001Medicare NSC
IL672430Medicare PIN