Healthcare Provider Details

I. General information

NPI: 1538169917
Provider Name (Legal Business Name): MIDWEST EYE CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N PARKWAY DR
PEKIN IL
61554-3932
US

IV. Provider business mailing address

101 N PARKWAY DR
PEKIN IL
61554-3932
US

V. Phone/Fax

Practice location:
  • Phone: 309-347-5115
  • Fax: 309-347-7036
Mailing address:
  • Phone: 309-347-5115
  • Fax: 309-347-7036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TRACI BACON
Title or Position: OFFICE MANGER
Credential:
Phone: 309-347-5115