Provider Demographics
NPI:1194054452
Name:TRISTATE PROFESSIONAL SERVICES INC
Entity type:Organization
Organization Name:TRISTATE PROFESSIONAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-259-8461
Mailing Address - Street 1:508 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:IL
Mailing Address - Zip Code:62561-8064
Mailing Address - Country:US
Mailing Address - Phone:217-259-8461
Mailing Address - Fax:217-522-4861
Practice Address - Street 1:2760 N DIRKSEN PKWY
Practice Address - Street 2:ATTN: WALMART VISION CTR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-1448
Practice Address - Country:US
Practice Address - Phone:217-522-4396
Practice Address - Fax:217-522-4861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006399152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty