Provider Demographics
NPI:1780671164
Name:HUTCHISON, BRENDA (OD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:HUTCHISON
Suffix:
Gender:F
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:2005-09-30
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008929152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0814870020OtherMEDICARE NSC NUMBER
IL180035690OtherMEDICARE RAILROAD
IL8929OtherEYEMED
IL0814870001OtherMEDICARE NSC NUMBER
237032OtherHARMONY HEALTH PLAN
050280OtherHEALTH ALLIANCE
IL046008929Medicaid
050280OtherHEALTH ALLIANCE
ILL68416Medicare PIN