Basic Information
| Provider Information | |||||||||
| NPI: | 1427099951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERRMANN | ||||||||
| FirstName: | TYSON | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 W ILES AVNEUE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176984728 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 W HAY ST | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625266328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176984728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046-009537 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046009537 | 05 | IL | MEDICAID | 180022789 | 01 | IL | RR MEDICARE | OTHER |