Provider Demographics
NPI:1700063765
Name:MCDOUG INC
Entity Type:Organization
Organization Name:MCDOUG INC
Other - Org Name:EYE TECH OPTICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:DELL
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-224-6168
Mailing Address - Street 1:804 STATE STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301
Mailing Address - Country:US
Mailing Address - Phone:217-224-6168
Mailing Address - Fax:217-224-5165
Practice Address - Street 1:804 STATE STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301
Practice Address - Country:US
Practice Address - Phone:217-224-6168
Practice Address - Fax:217-224-5165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6036530001Medicare NSC