MEDICARE: DR. IRENE D COMBS 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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01635462	OTHER	IL	BC/BS

General Provider Information

NPI Number	:	1700814530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRENE D COMBS O.D.

Provider Business Mailing Address
First Line	:	504 HILLGROVE AVE
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-1481
Country	:	US
Telephone Number	:	708-286-1100
Fax Number	:	708-286-1103

Provider Business Practice Location Address
First Line	:	504 HILLGROVE AVE
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-1481
Country	:	US
Telephone Number	:	708-286-1100
Fax Number	:	708-286-1103

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	03/26/2008

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