MEDICARE: KELLY RAETHER O.D.

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	046-009772	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1578798989	OTHER		NPI

General Provider Information

NPI Number	:	1356413223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY RAETHER O.D.

Provider Business Mailing Address
First Line	:	680 N LAKE SHORE DR STE 1000
Second Line	:	ATTN: MARTHA HOLDER
City	:	CHICAGO
State	:	IL
Zip	:	60611-8709
Country	:	US
Telephone Number	:	847-295-0001
Fax Number	:

Provider Business Practice Location Address
First Line	:	1475 E BELVIDERE RD STE 1297
Second Line	:	NORTHWESTERN OPHTHALMOLOGY DEPARTMENT
City	:	GRAYSLAKE
State	:	IL
Zip	:	60030-2026
Country	:	US
Telephone Number	:	847-295-0001
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	11/17/2015

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