=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033385141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTIOCH EYE ASSOCIATES OD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2008
-----------------------------------------------------
Last Update Date | 12/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 884 HILLSIDE AVE
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60002-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-395-4090
-----------------------------------------------------
Fax | 847-395-7378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 884 HILLSIDE AVE
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60002-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-395-4090
-----------------------------------------------------
Fax | 847-395-7378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CONNIE J CRAWFROD
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 847-395-4090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046009062
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046007913
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------