Healthcare Provider Details

I. General information

NPI: 1750765012
Provider Name (Legal Business Name): ILLINOIS RETINA ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 W 156TH ST STE 400
HARVEY IL
60426-4265
US

IV. Provider business mailing address

71 W 156TH ST STE 400
HARVEY IL
60426-4265
US

V. Phone/Fax

Practice location:
  • Phone: 708-596-8710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY FREDERICK
Title or Position: BILLING MANAGER
Credential:
Phone: 708-915-6963