Healthcare Provider Details

I. General information

NPI: 1376711283
Provider Name (Legal Business Name): C E MYERS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 106
PEORIA IL
61614-5098
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE
PEORIA IL
61614-5098
US

V. Phone/Fax

Practice location:
  • Phone: 309-693-2710
  • Fax: 309-693-9460
Mailing address:
  • Phone: 309-693-2710
  • Fax: 309-693-9460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number36060306
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number36060306
License Number StateIL

VIII. Authorized Official

Name: DR. CLIFFORD EARL MYERS
Title or Position: OWNER
Credential: M.D.
Phone: 309-693-2710