Healthcare Provider Details

I. General information

NPI: 1790746428
Provider Name (Legal Business Name): MIDWEST EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E WEST RD
CALUMET CITY IL
60409-5415
US

IV. Provider business mailing address

1700 E WEST RD
CALUMET CITY IL
60409-5415
US

V. Phone/Fax

Practice location:
  • Phone: 708-891-3330
  • Fax: 708-891-0904
Mailing address:
  • Phone: 708-891-3330
  • Fax: 708-891-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE L NEAL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 469-214-0144