Healthcare Provider Details

I. General information

NPI: 1457347346
Provider Name (Legal Business Name): MARY AGNES BIGELOW O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E MAIN ST
BEARDSTOWN IL
62618-1241
US

IV. Provider business mailing address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

V. Phone/Fax

Practice location:
  • Phone: 217-323-1146
  • Fax: 217-323-1156
Mailing address:
  • Phone: 217-698-3030
  • Fax: 217-698-4728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02559
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: