Basic Information
| Provider Information | |||||||||
| NPI: | 1639166226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHAIDLE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8309 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616152170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096939540 | ||||||||
| FaxNumber: | 3096939542 | ||||||||
| Practice Location | |||||||||
| Address1: | 4620 N UNIVERSITY ST | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616145889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096928222 | ||||||||
| FaxNumber: | 3096928226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046008408 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046008408 | 05 | IL | MEDICAID | 410033418 | 01 | IL | MEDICARE RAILROAD | OTHER | 7215175 | 01 | IL | BCBS | OTHER |