Provider Demographics
NPI:1013967116
Name:MARK A ELLISON, LTD
Entity Type:Organization
Organization Name:MARK A ELLISON, LTD
Other - Org Name:FAMILY VISION CARE OF SOUTHERN ILLINOIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-635-2424
Mailing Address - Street 1:422 W BETHALTO DR
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-1700
Mailing Address - Country:US
Mailing Address - Phone:618-377-5221
Mailing Address - Fax:618-377-5220
Practice Address - Street 1:422 W BETHALTO DR
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010-1700
Practice Address - Country:US
Practice Address - Phone:618-377-5221
Practice Address - Fax:618-377-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007313152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0241360001Medicare NSC
ILT37740Medicare UPIN
ILDH1681Medicare PIN
IL976180Medicare PIN