Healthcare Provider Details

I. General information

NPI: 1528020401
Provider Name (Legal Business Name): EYE SPECIALIST OF SOUTHERN ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W DEYOUNG ST
MARION IL
62959-1630
US

IV. Provider business mailing address

1429 N MOUNT AUBURN RD
CAPE GIRARDEAU MO
63701-2171
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-0068
  • Fax: 618-993-0968
Mailing address:
  • Phone: 573-335-9175
  • Fax: 573-334-3390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID C ANDERSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 573-335-9175