Basic Information
| Provider Information | |||||||||
| NPI: | 1689753675 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARVIN H HEIMLICH,OD LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIBERTYVILLE VISION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 S MILWAUKEE AVE | ||||||||
| Address2: | LIBERTYVILLE VISION CENTER | ||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473623444 | ||||||||
| FaxNumber: | 8473624672 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 S MILWAUKEE AVE | ||||||||
| Address2: | LIBERTYVILLE VISION CENTER | ||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473623444 | ||||||||
| FaxNumber: | 8473624672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 03/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | HEIMLICH | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | HAROLD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8473626444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 4915133 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER | IL7448-001 | 01 | IL | EYEMED VISION CARE | OTHER | 2116789 | 01 | IL | AETNA | OTHER |