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General NPI Number Information
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NPI Number | 1710105101
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Entity Type | Organization
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Legal Business Name | ILLINOIS EYE SPECIALISTS
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 05/02/2012
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Provider Practice Location Address
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Address Line | 2421 CORPORATE CTR STE 102
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City | GRANITE CITY
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State | IL
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Zip | 62040-4195
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Country | US
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Telephone | 618-931-6980
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Fax | 618-931-2470
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Provider Business Mailing Address
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Address Line | 2421 CORPORATE CTR STE 102
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City | GRANITE CITY
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State | IL
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Zip | 62040-4195
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Country | US
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Telephone | 618-931-6980
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Fax | 618-931-2470
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDWARD A DOISY III
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Credential | M.D.
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Telephone | 618-931-6980
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 336017108
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License Number State | IL
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