Provider Demographics
NPI:1841563681
Name:EDWARD L MONTWILL OD, LTD.
Entity Type:Organization
Organization Name:EDWARD L MONTWILL OD, LTD.
Other - Org Name:PALOS VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONTWILL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-361-5236
Mailing Address - Street 1:11749 SOUTHWEST HWY # C
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1053
Mailing Address - Country:US
Mailing Address - Phone:708-361-5236
Mailing Address - Fax:708-361-5489
Practice Address - Street 1:11749 SOUTHWEST HWY # C
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1053
Practice Address - Country:US
Practice Address - Phone:708-361-5236
Practice Address - Fax:708-361-5489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.008324152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL948820OtherPTAN
IL948820Medicare PIN