Provider Demographics
NPI:1962696617
Name:PATRICK NIEBRUGGE OD
Entity type:Organization
Organization Name:PATRICK NIEBRUGGE OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:NIEBRUGGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-932-2310
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:1279 E US HWY 40
Mailing Address - City:CASEY
Mailing Address - State:IL
Mailing Address - Zip Code:62420-0528
Mailing Address - Country:US
Mailing Address - Phone:217-932-2310
Mailing Address - Fax:217-932-4674
Practice Address - Street 1:1279 E US HWY 40
Practice Address - Street 2:
Practice Address - City:CASEY
Practice Address - State:IL
Practice Address - Zip Code:62420-0528
Practice Address - Country:US
Practice Address - Phone:217-932-2310
Practice Address - Fax:217-932-4674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0706010001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007315Medicaid
IL1831228600OtherNPI
IL1831228600OtherNPI
IL683840Medicare PIN
0706010001Medicare NSC