Provider Demographics
NPI:1689601940
Name:RETINA CONSULTANTS OF CENTRAL ILLINOIS, SC
Entity Type:Organization
Organization Name:RETINA CONSULTANTS OF CENTRAL ILLINOIS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHITTARANJAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-693-2249
Mailing Address - Street 1:PO BOX 1466
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53008-1466
Mailing Address - Country:US
Mailing Address - Phone:262-788-9229
Mailing Address - Fax:262-788-9241
Practice Address - Street 1:3310 WEST CHARTWELL ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-693-2249
Practice Address - Fax:309-693-2583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090651207W00000X
IL042-616854207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6422Medicare PIN
IL372970Medicare ID - Type Unspecified
IL531788220Medicaid
ILIL6422Medicare PIN