MEDICARE: MS. ANDREA GRIDER OD

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	046011312	IL
2	152W00000X	Optometrist	046.011312	IL

General Provider Information

NPI Number	:	1861051773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANDREA GRIDER OD

Provider Business Mailing Address
First Line	:	9661 W 143RD ST STE 202
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60462-2088
Country	:	US
Telephone Number	:	708-361-6141
Fax Number	:	708-361-5327

Provider Business Practice Location Address
First Line	:	9661 W 143RD ST STE 202
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60462-2088
Country	:	US
Telephone Number	:	708-361-6141
Fax Number	:	708-361-5327

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

Provider Enumeration Date	:	06/13/2019
Last Update Date	:	07/26/2021

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