Provider Demographics
NPI:1053593186
Name:GEORGE A ROEBUCK
Entity type:Organization
Organization Name:GEORGE A ROEBUCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROEBUCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-942-1951
Mailing Address - Street 1:113 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-2101
Mailing Address - Country:US
Mailing Address - Phone:815-942-1951
Mailing Address - Fax:815-942-1958
Practice Address - Street 1:113 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-2101
Practice Address - Country:US
Practice Address - Phone:815-942-1951
Practice Address - Fax:815-942-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007227152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0335980001Medicare NSC