MEDICARE: J. MICETICH, OD & ASSOCIATES FAMILY EYE CARE CENTER P C

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	152W00000X	Optometrist	046-008925	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	DR0848	OTHER		RAILROAD MEDICARE GROUP PTAN
5	410047901	OTHER		RAILROAD MEDICARE GROUP MEMBER PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	03232003	OTHER	IL	BCBS
3	1740273754	OTHER	IL	PERSONAL NPI

General Provider Information

NPI Number	:	1093832008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. MICETICH, OD & ASSOCIATES FAMILY EYE CARE CENTER P C

Provider Business Mailing Address
First Line	:	2920 GATEWAY GORGE
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-9771
Country	:	US
Telephone Number	:	815-634-4825
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 E NORTH ST
Second Line	:
City	:	COAL CITY
State	:	IL
Zip	:	60416-1087
Country	:	US
Telephone Number	:	815-634-4825
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. JONATHAN EDWARD MICETICH
Credential	:	O.D.
Telephone Number	:	815-634-4825

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	09/18/2012

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Directions to “J. MICETICH, OD & ASSOCIATES FAMILY EYE CARE CENTER P C ” Practice Location

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