Provider Demographics
NPI:1578766515
Name:PRAIRIE EYE CENTER, LTD
Entity Type:Organization
Organization Name:PRAIRIE EYE CENTER, LTD
Other - Org Name:JACKSONVILLE OPHTHALMOLOGIC ASSOCIATES LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-698-3030
Mailing Address - Street 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7015
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-4728
Practice Address - Street 1:2000 W MORTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2623
Practice Address - Country:US
Practice Address - Phone:217-245-6814
Practice Address - Fax:217-245-0375
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE EYE CENTER, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-07
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207WX0107X
IL036-051855207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0576200001Medicare NSC