NPIMap

Organization Active NPI

Salem Eye Clinic LLC

  • Optometrist
  • Salem, IL
National Provider Identifier
1205980786
Registry record updated Mar 28, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
SALEM EYE CLINIC LLC
Practice address
400 North Broadway
Salem, IL 62881
Phone
(618) 548-3506
Fax
(618) 548-2555
NPI assigned
Jan 22, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 28, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Alan D Montgomery, ODNPI 1326192808
Title
Owner
Phone
(618) 548-3506

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X Primary

Addresses

Primary practice location

400 North Broadway
Salem, IL 62881

Mailing address

400 North Broadway
Salem, IL 62881
Phone (618) 548-3506

Other identifiers 1

IdentifierTypeStateIssuer
06132027OtherILBLUE CROSS BLUE SHIELD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050927001009 IL Part B Supplier - Clinic/Group Practice 1456386697 Receives reassigned benefits from 4 practitioners
Practice locations: Salem, IL
O20100930091449 IL DME Supplier - Physician - Optometrist 1456386697 Practice locations: Salem, IL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Salem Eye Clinic, LLC400 N Broadway Ave, Salem, IL 62881-1514(618) 548-3506 Prosthetic Lenses: Conventional Eyeglasses|Prosthetic Lenses: Conventional Contact Lenses|Prosthetic Lenses: Prosthetics Cataract Lenses Accepts assignmentParticipating since Mar 7, 2000

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169424000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1206662400000",
    "number": "1205980786",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 NORTH BROADWAY",
            "city": "SALEM",
            "state": "IL",
            "postal_code": "62881",
            "telephone_number": "618-548-3506",
            "fax_number": "618-548-2555"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 NORTH BROADWAY",
            "city": "SALEM",
            "state": "IL",
            "postal_code": "62881",
            "telephone_number": "618-548-3506",
            "fax_number": "618-548-2555"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SALEM EYE CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-22",
        "last_updated": "2008-03-28",
        "status": "A",
        "authorized_official_last_name": "MONTGOMERY",
        "authorized_official_first_name": "ALAN",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "618-548-3506",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "06132027",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Salem, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 28, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.