Provider Demographics
NPI:1427174960
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:DEBRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMOTHERS-CHAMPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-824-4991
Mailing Address - Street 1:623 PULASKI ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-2825
Mailing Address - Country:US
Mailing Address - Phone:217-732-9606
Mailing Address - Fax:217-732-4580
Practice Address - Street 1:623 PULASKI ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-2825
Practice Address - Country:US
Practice Address - Phone:217-732-9606
Practice Address - Fax:217-732-4580
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
IL046008739152W00000X
IL046008024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001115000OtherBC BS GROUP NUMBER
IL046008739Medicaid
IL046008024Medicaid
ILL32709Medicare ID - Type UnspecifiedDR. RABE
ILL38179Medicare ID - Type UnspecifiedSMOTHERS-CHAMPLEY
IL0001115000OtherBC BS GROUP NUMBER
IL0312490004Medicare NSC
ILU57444Medicare UPIN
IL353010Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER