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GREAT RIVERS EYE CARE
Complete NPI Record 1770294449
Optometrist in Jerseyville, IL

NPI Status: Active since December 13, 2022

Contact Information

519 S STATE ST
JERSEYVILLE, IL
ZIP 62052
Phone: (217) 342-2672

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider First Line Business Mailing Address
  6. Provider Business Mailing Address City Name
  7. Provider Business Mailing Address State Name
  8. Provider Business Mailing Address Postal Code
  9. Provider Business Mailing Address Country Code If outside U S
  10. Provider Business Mailing Address Telephone Number
  11. Provider Business Mailing Address Fax Number
  12. Provider First Line Business Practice Location Address
  13. Provider Business Practice Location Address City Name
  14. Provider Business Practice Location Address State Name
  15. Provider Business Practice Location Address Postal Code
  16. Provider Business Practice Location Address Country Code If outside U S
  17. Provider Business Practice Location Address Telephone Number
  18. Provider Enumeration Date
  19. Last Update Date
  20. Authorized Official Last Name
  21. Authorized Official First Name
  22. Authorized Official Middle Name
  23. Authorized Official Title or Position
  24. Authorized Official Telephone Number
  25. Healthcare Provider Taxonomy Code 1
  26. Healthcare Provider Primary Taxonomy Switch 1
  27. Healthcare Provider Taxonomy Code 2
  28. Healthcare Provider Primary Taxonomy Switch 2
  29. Is Organization Subpart
  30. Authorized Official Name Prefix Text
  31. NPI Certification Date

Complete NPI Dataset

This page represents the complete record for NPI 1770294449. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1770294449
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: UNAVAIL
The city name in the mailing address of the provider being identified.
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider First Line Business Mailing Address: 303 N KELLER DR
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address City Name: EFFINGHAM
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider Business Mailing Address State Name: IL
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider Business Mailing Address Postal Code: 624011859
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Mailing Address Country Code If outside U S : US
The city name in the location address of the provider being identified.
Provider Business Mailing Address Telephone Number: 2173422672
The State code in the location of the provider being identified.
Provider Business Mailing Address Fax Number: 2173422681
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider First Line Business Practice Location Address: 519 S STATE ST
The country code in the location address of the provider being identified.
Provider Business Practice Location Address City Name: JERSEYVILLE
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address State Name: IL
The date the provider was assigned a unique identifier (assigned an NPI).
Provider Business Practice Location Address Postal Code: 620522241
The date that a record was last updated or changed.
Provider Business Practice Location Address Country Code If outside U S : US
The code designating the provider’s gender if the provider is a person.
Provider Business Practice Location Address Telephone Number: 2173422672
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Provider Enumeration Date: 12/13/2022
The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
Last Update Date: 10/9/2024
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
Authorized Official Last Name: SMITH
Authorized Official First Name: MICHELLE
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Authorized Official Middle Name: A
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Authorized Official Title or Position: DIRECTOR OF OPERATIONS
The title or position of the authorized official.
Authorized Official Telephone Number: 2173422672
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 152W00000X
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1: Y
Healthcare Provider Taxonomy Code 2: 332H00000X
Healthcare Provider Primary Taxonomy Switch 2: N
Is Organization Subpart: N
Authorized Official Name Prefix Text: MS.
NPI Certification Date: 10/9/2024