Provider Demographics
NPI:1558352641
Name:CRABTREE AND MERRIMAN DCTRS OF OPTOMETRY
Entity Type:Organization
Organization Name:CRABTREE AND MERRIMAN DCTRS OF OPTOMETRY
Other - Org Name:JACOBS & CRABTREE DCTRS OF OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-529-4817
Mailing Address - Street 1:1508 SIOUX DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5200
Mailing Address - Country:US
Mailing Address - Phone:618-993-8787
Mailing Address - Fax:618-997-6547
Practice Address - Street 1:1001 N BEADLE DR
Practice Address - Street 2:STE 40
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1018
Practice Address - Country:US
Practice Address - Phone:618-529-4817
Practice Address - Fax:618-351-9024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-29
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007399152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0709640003Medicare NSC
ILT37858Medicare UPIN
ILU03048Medicare UPIN
ILT37858Medicare UPIN
IL688832Medicare ID - Type Unspecified