Basic Information
| Provider Information | |||||||||
| NPI: | 1710105101 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS EYE SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2421 CORPORATE CTR STE 102 | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620404195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189316980 | ||||||||
| FaxNumber: | 6189312470 | ||||||||
| Practice Location | |||||||||
| Address1: | 2421 CORPORATE CTR STE 102 | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620404195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189316980 | ||||||||
| FaxNumber: | 6189312470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | DOISY | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6189316980 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 336017108 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.