Provider Demographics
NPI:1649475328
Name:PAUL C JACOBS TREVOR CRABTREE PTR
Entity type:Organization
Organization Name:PAUL C JACOBS TREVOR CRABTREE PTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-993-8787
Mailing Address - Street 1:1508 SIOUX DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5200
Mailing Address - Country:US
Mailing Address - Phone:618-993-8787
Mailing Address - Fax:618-997-6547
Practice Address - Street 1:223 N PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3149
Practice Address - Country:US
Practice Address - Phone:618-942-6887
Practice Address - Fax:618-988-1209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008310152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0709640001Medicare NSC
931260Medicare PIN