Healthcare Provider Details

I. General information

NPI: 1629878079
Provider Name (Legal Business Name): GREAT LAKES RETINA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2025
Last Update Date: 03/15/2025
Certification Date: 03/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3438 N OLD ARLINGTON HEIGHTS RD
ARLINGTON HEIGHTS IL
60004-1552
US

IV. Provider business mailing address

3438 N OLD ARLINGTON HEIGHTS RD
ARLINGTON HEIGHTS IL
60004-1552
US

V. Phone/Fax

Practice location:
  • Phone: 847-551-0049
  • Fax: 847-787-1657
Mailing address:
  • Phone: 847-551-0049
  • Fax: 847-787-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OMAR MOHAMED HASSAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 847-551-0049