Provider Demographics
NPI:1427174275
Name:CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD
Entity type:Organization
Organization Name:CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:RABE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-824-4991
Mailing Address - Street 1:900 W SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1213
Mailing Address - Country:US
Mailing Address - Phone:217-824-4991
Mailing Address - Fax:217-824-5414
Practice Address - Street 1:900 W SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1213
Practice Address - Country:US
Practice Address - Phone:217-824-4991
Practice Address - Fax:217-824-5414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006087152W00000X
IL046008739152W00000X
IL046008024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001115000OtherBC BS GROUP NUMBER
IL046008024Medicaid
IL046008739Medicaid
IL410029982OtherSMOTHERS RAILROAD NUMBER
IL046006087Medicaid
IL410015010OtherRABE RAILROAD NUMBER
IL410015009OtherBLACKMAN RAILROAD NUMBER
IL410015010OtherRABE RAILROAD NUMBER
IL0001115000OtherBC BS GROUP NUMBER
IL410029982OtherSMOTHERS RAILROAD NUMBER
ILT38877Medicare UPIN
ILT35907Medicare UPIN
IL046006087Medicaid
IL046008024Medicaid
IL0312490001Medicare NSC