Provider Demographics
NPI:1710105101
Name:ILLINOIS EYE SPECIALISTS
Entity Type:Organization
Organization Name:ILLINOIS EYE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOISY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:618-931-6980
Mailing Address - Street 1:2421 CORPORATE CTR STE 102
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4195
Mailing Address - Country:US
Mailing Address - Phone:618-931-6980
Mailing Address - Fax:618-931-2470
Practice Address - Street 1:2421 CORPORATE CTR STE 102
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4195
Practice Address - Country:US
Practice Address - Phone:618-931-6980
Practice Address - Fax:618-931-2470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336017108207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C44292Medicare UPIN