Provider Demographics
NPI:1598947343
Name:KERN OPTOMETRIC ASSOCIATES PC
Entity Type:Organization
Organization Name:KERN OPTOMETRIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-682-6244
Mailing Address - Street 1:4408 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-682-6214
Mailing Address - Fax:309-682-6236
Practice Address - Street 1:4408 N KNOXVILLE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-682-6214
Practice Address - Fax:309-682-6236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007198152W00000X
IL0467198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007198Medicaid
1497812242OtherNPI INDIVIDUAL CROSSOVER
IL046007198Medicaid
1497812242OtherNPI INDIVIDUAL CROSSOVER
IL264450Medicare PIN