Basic Information
| Provider Information | |||||||||
| NPI: | 1790715662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIEBELHAUSEN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 W ILES AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627047015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176984728 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W MORTON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626502623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172456814 | ||||||||
| FaxNumber: | 2172450375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 01/14/2014 | ||||||||
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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 | 174400000X | 036051855 | IL | N | Other Service Providers | Specialist | 207W00000X | 036051855 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 036051855 | 05 | IL | MEDICAID |