Provider Demographics
NPI:1194715953
Name:WAYNE, EILEEN MARIE (MD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:MARIE
Last Name:WAYNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 35TH AVENUE PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8026
Mailing Address - Country:US
Mailing Address - Phone:309-736-0808
Mailing Address - Fax:
Practice Address - Street 1:840 35TH AVENUE PL
Practice Address - Street 2:SUITE 101
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-8026
Practice Address - Country:US
Practice Address - Phone:309-736-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051328207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051328Medicaid
IL8100324OtherBLUE CROSS BLUE SHIELD
C37637Medicare UPIN
IL036051328Medicaid