Provider Demographics
NPI:1053572255
Name:DECATUR EYECARE ASSOCIATES
Entity type:Organization
Organization Name:DECATUR EYECARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BEDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-422-8032
Mailing Address - Street 1:1270 S JASPER ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3531
Mailing Address - Country:US
Mailing Address - Phone:217-422-8032
Mailing Address - Fax:
Practice Address - Street 1:1270 S JASPER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3531
Practice Address - Country:US
Practice Address - Phone:217-422-8032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL467080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL714680OtherMEDICARE ID
IL4095740001OtherDMERC MEDICARE
IL046007080Medicaid
IL0005884011OtherBLUE CROSS AND SHIELD OF ILLINOIS
IL410017583OtherRAILROAD MEDICARE
IL046007080Medicaid
IL0005884011OtherBLUE CROSS AND SHIELD OF ILLINOIS
IL4095740001OtherDMERC MEDICARE