Provider Demographics
NPI:1568656023
Name:ILLINI EYECARE MONTICELLO INC
Entity Type:Organization
Organization Name:ILLINI EYECARE MONTICELLO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-762-2551
Mailing Address - Street 1:102 S CHARTER ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1853
Mailing Address - Country:US
Mailing Address - Phone:217-762-2551
Mailing Address - Fax:
Practice Address - Street 1:102 S CHARTER ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1853
Practice Address - Country:US
Practice Address - Phone:217-762-2551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007835152WP0200X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6237070001Medicare NSC
ILU03055Medicare UPIN
IL215778Medicare PIN