Provider Demographics
NPI:1558466912
Name:ROGER W FITCH OD
Entity Type:Organization
Organization Name:ROGER W FITCH OD
Other - Org Name:CARVER OPTICAL- VISION CARE OUTREACH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:W
Authorized Official - Last Name:FITCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-691-4500
Mailing Address - Street 1:4900 N GLEN PARK PLACE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4679
Mailing Address - Country:US
Mailing Address - Phone:309-691-4500
Mailing Address - Fax:309-693-2534
Practice Address - Street 1:4900 N GLEN PARK PLACE RD
Practice Address - Street 2:SUITE C
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4679
Practice Address - Country:US
Practice Address - Phone:309-691-4500
Practice Address - Fax:309-693-2534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006836152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty