Healthcare Provider Details

I. General information

NPI: 1548484082
Provider Name (Legal Business Name): FAHY AND FAHY OPTOMETRIST, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5943 W MONTROSE AVE
CHICAGO IL
60634-1629
US

IV. Provider business mailing address

5943 W MONTROSE AVE
CHICAGO IL
60634-1629
US

V. Phone/Fax

Practice location:
  • Phone: 773-685-0364
  • Fax: 773-668-0944
Mailing address:
  • Phone: 773-685-0364
  • Fax: 773-668-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number046007793
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY FAHY
Title or Position: PRESIDENT
Credential: O.D.
Phone: 773-685-0363