MEDICARE: RIVERBEND OPHTHALMOLOGISTS, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DA7199	OTHER	IL	MEDICARE RR

General Provider Information

NPI Number	:	1013994151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERBEND OPHTHALMOLOGISTS, LTD

Provider Business Mailing Address
First Line	:	1310 DADRIAN PROFESSIONAL PARK
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-1685
Country	:	US
Telephone Number	:	618-433-5005
Fax Number	:	618-467-1053

Provider Business Practice Location Address
First Line	:	1310 DADRIAN PROFESSIONAL PARK
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-1685
Country	:	US
Telephone Number	:	618-433-5005
Fax Number	:	618-467-1053

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES MELVIN HUDSON
Credential	:	M.D.
Telephone Number	:	618-433-5005

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	06/04/2010

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