Healthcare Provider Details

I. General information

NPI: 1164981916
Provider Name (Legal Business Name): AVREY THAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 09/22/2024
Certification Date: 09/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 W IRVING PARK RD STE 330
CHICAGO IL
60641-2808
US

IV. Provider business mailing address

259 E ERIE ST STE 1520
CHICAGO IL
60611-3111
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8150
  • Fax: 312-921-0385
Mailing address:
  • Phone: 312-695-8150
  • Fax: 312-695-3652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number036164051
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: