Basic Information
| Provider Information | |||||||||
| NPI: | 1457347346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIGELOW | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | AGNES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 W ILES AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627044174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176984728 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BEARDSTOWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626181241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173231146 | ||||||||
| FaxNumber: | 2173231156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 09/06/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | T02559 | MO | N | Eye and Vision Services Providers | Optometrist | 152W00000X | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | P00390109 | 01 | GA | RAILROAD MEDICARE | OTHER |