Kevin Goodwin
Individual provider Active NPI Optometrist · Montgomery, IL
NPI 1740697408 · NPPES record last updated Jul 15, 2014
Key facts
- NPI
- 1740697408
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- 046010826 (IL)
- Practice address
- 1050 Ogden Ave
Montgomery, IL 60538-5404 - Phone
- (630) 449-1955
- NPI assigned
- Jul 15, 2014
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare Care Compare profile
- Specialty
- Optometry
- Education
- Illinois College of Optometry at Chicago, 2014
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Tyler Ridge Vision Care, LTD
Practice addresses (Care Compare)
1001 E Main St
Suite C
St Charles, IL 60174-2203
Phone (630) 584-1111
Procedures performed for Medicare patients
| Procedure | Number of procedures |
|---|---|
| Cataract surgery | 1-10 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190116003037 | IL | Practitioner - Optometry | 5193061836 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 046010826 | IL | MD | Optometrist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Tyler Ridge Vision Care, LTD. | Optometrist | Current |
Accepting new patients |
Locations
1001 E Main St
Ste C
St Charles, IL 60174
Phone (630) 584-1111
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 046010826 | IL | Yes |
Addresses
Primary practice location
1050 Ogden Ave
Montgomery, IL 60538-5404
Mailing address
653 W Briarcliff Rd
Bolingbrook, IL 60440-2630
Phone (630) 908-0892
Other providers in Montgomery, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 15, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.