Provider Demographics
NPI:1851417513
Name:CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD
Other - Org Name:ADVANCED EYECARE OF CARLINVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-854-3173
Mailing Address - Street 1:615 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1020
Mailing Address - Country:US
Mailing Address - Phone:217-854-3173
Mailing Address - Fax:
Practice Address - Street 1:615 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1020
Practice Address - Country:US
Practice Address - Phone:217-854-3173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008125152W00000X
IL046006408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046006408Medicaid
IL410042496OtherRUBRICH RAILROAD NUMBER
IL410042452OtherHEDRICK RAILROAD NUMBER
IL0001115000OtherBC BS GROUP NUMBER
IL046008125Medicaid
IL046006408Medicaid
ILT35435Medicare UPIN
ILL30637Medicare ID - Type UnspecifiedHEDRICK MEDICARE
IL046008125Medicaid
IL0001115000OtherBC BS GROUP NUMBER
IL0312490005Medicare NSC