Basic Information
| Provider Information | |||||||||
| NPI: | 1013994151 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERBEND OPHTHALMOLOGISTS, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 DADRIAN PROFESSIONAL PARK | ||||||||
| Address2: | |||||||||
| City: | GODFREY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620351685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184335005 | ||||||||
| FaxNumber: | 6184671053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 DADRIAN PROFESSIONAL PARK | ||||||||
| Address2: | |||||||||
| City: | GODFREY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620351685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184335005 | ||||||||
| FaxNumber: | 6184671053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 06/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | HUDSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | MELVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6184335005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | DA7199 | 01 | IL | MEDICARE RR | OTHER |