Provider Demographics
NPI:1528020401
Name:EYE SPECIALIST OF SOUTHERN ILLINOIS, LLC
Entity Type:Organization
Organization Name:EYE SPECIALIST OF SOUTHERN ILLINOIS, LLC
Other - Org Name:KIES EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-335-9175
Mailing Address - Street 1:1429 N MOUNT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2171
Mailing Address - Country:US
Mailing Address - Phone:573-335-9175
Mailing Address - Fax:573-334-3390
Practice Address - Street 1:1000 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1630
Practice Address - Country:US
Practice Address - Phone:618-993-0068
Practice Address - Fax:618-993-0968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10032015OtherBLUECROSS BLUESHIELD
ILCK8965OtherRAILROAD MEDICARE
IL10032015OtherBLUECROSS BLUESHIELD