MEDICARE: EDWARD L MONTWILL OD, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046.008324	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	948820	OTHER	IL	PTAN

General Provider Information

NPI Number	:	1841563681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARD L MONTWILL OD, LTD.

Provider Business Mailing Address
First Line	:	11749 SOUTHWEST HWY # C
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1053
Country	:	US
Telephone Number	:	708-361-5236
Fax Number	:	708-361-5489

Provider Business Practice Location Address
First Line	:	11749 SOUTHWEST HWY # C
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1053
Country	:	US
Telephone Number	:	708-361-5236
Fax Number	:	708-361-5489

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EDWARD L MONTWILL
Credential	:	O.D.
Telephone Number	:	708-361-5236

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	02/09/2012

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