Provider Demographics
NPI:1902009632
Name:TYHURST, KEITH (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:TYHURST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:1200 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4437
Practice Address - Country:US
Practice Address - Phone:618-993-5686
Practice Address - Fax:618-997-6250
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009941152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0814870001OtherMEDICARE NSC NUMBER
IL0814870025OtherMEDICARE NSC NUMBER
IL0814870031OtherMEDICARE NSC NUMBER
IL9941OtherEYEMED
ILP00418695OtherMEDICARE RAILROAD
IL0814870007OtherMEDICARE NSC NUMBER
IL0814870008OtherMEDICARE NSC NUMBER
IL0814870022OtherMEDICARE NSC NUMBER
IL046009941Medicaid
134731OtherHEALTH ALLIANCE
ILP00418695OtherMEDICARE RAILROAD