Provider Demographics
NPI:1306989553
Name:BALGEMANN OPTOMETRY GROUP, INC.
Entity type:Organization
Organization Name:BALGEMANN OPTOMETRY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:BALGEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-864-6191
Mailing Address - Street 1:2515 N PROSPECT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1226
Mailing Address - Country:US
Mailing Address - Phone:217-378-2934
Mailing Address - Fax:217-378-2936
Practice Address - Street 1:2515 N PROSPECT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1226
Practice Address - Country:US
Practice Address - Phone:217-378-2934
Practice Address - Fax:217-378-2936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty