MEDICARE: THADDEUS

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1336331909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THADDEUS

Provider Business Mailing Address
First Line	:	4812 N. MILWAUKEE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646
Country	:	US
Telephone Number	:	773-545-2660
Fax Number	:

Provider Business Practice Location Address
First Line	:	4812 N. MILWAUKEE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646
Country	:	US
Telephone Number	:	773-545-2660
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SPENCER P VIDULICH
Credential	:	O.D.
Telephone Number	:	773-327-3000

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	10/04/2007

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Directions to “THADDEUS ” Practice Location

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