Provider Demographics
NPI:1811159049
Name:DORIS ANN OSBORNE ELS OD
Entity type:Organization
Organization Name:DORIS ANN OSBORNE ELS OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-548-4866
Mailing Address - Street 1:121 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1509
Mailing Address - Country:US
Mailing Address - Phone:618-548-4866
Mailing Address - Fax:618-548-4867
Practice Address - Street 1:121 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1509
Practice Address - Country:US
Practice Address - Phone:618-548-4866
Practice Address - Fax:618-548-4867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-29
Last Update Date:2008-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0152110001Medicare NSC