Provider Demographics
NPI:1609072263
Name:CRABTREE & MERRIMAN-DOCTORS OF OPTOMETRY
Entity Type:Organization
Organization Name:CRABTREE & MERRIMAN-DOCTORS OF OPTOMETRY
Other - Org Name:JACOBS & CRABTREE DCTRS OF OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CELISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-697-4673
Mailing Address - Street 1:1508 SIOUX DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5209
Mailing Address - Country:US
Mailing Address - Phone:618-993-8787
Mailing Address - Fax:618-997-6547
Practice Address - Street 1:1508 SIOUX DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5209
Practice Address - Country:US
Practice Address - Phone:618-993-8787
Practice Address - Fax:618-997-6547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008310152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA410048440OtherPALMETTO GBA - RAILROAD MEDICARE
ILIL4660Medicare PIN
ILA410048440OtherPALMETTO GBA - RAILROAD MEDICARE
931260Medicare PIN