Provider Demographics
NPI:1013914571
Name:HEDRICK, KEITH T (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:T
Last Name:HEDRICK
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 1:615 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:217-854-4123
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:217-854-4123
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT35435Medicare UPIN