Healthcare Provider Details

I. General information

NPI: 1164569380
Provider Name (Legal Business Name): RETINAL VITREAL CONSULTANTS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S MICHIGAN AVE STE 212
CHICAGO IL
60616-2859
US

IV. Provider business mailing address

PO BOX 166516
CHICAGO IL
60616-6516
US

V. Phone/Fax

Practice location:
  • Phone: 312-567-2795
  • Fax: 800-707-4890
Mailing address:
  • Phone: 312-567-2795
  • Fax: 800-707-4890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHAUN T ITTIARA
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 312-567-2795