MEDICARE: EYE SEE RAVENSWOOD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046009834	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1205388193	OTHER	IL	NPI

General Provider Information

NPI Number	:	1285875823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE SEE RAVENSWOOD, PC

Provider Business Mailing Address
First Line	:	4735 NORTH DAMEN AVE
Second Line	:	EYE SEE RAVENSWOOD, PC
City	:	CHICAGO
State	:	IL
Zip	:	60640
Country	:	US
Telephone Number	:	773-961-8700
Fax Number	:	773-961-8703

Provider Business Practice Location Address
First Line	:	4735 NORTH DAMEN AVE
Second Line	:	EYE SEE RAVENSWOOD, PC
City	:	CHICAGO
State	:	IL
Zip	:	60640
Country	:	US
Telephone Number	:	773-961-8700
Fax Number	:	773-961-8703

Authorized Official
Title or Position	:	OWNER
Name	:	ANDREA J STEIN
Credential	:	O.D.
Telephone Number	:	773-961-8700

Provider Enumeration Date	:	03/11/2009
Last Update Date	:	03/11/2009

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