Healthcare Provider Details

I. General information

NPI: 1003875436
Provider Name (Legal Business Name): ILLINOIS RETINA INSTITUTE, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3602 MARQUETTE RD
PERU IL
61354-1450
US

IV. Provider business mailing address

PO BOX 36
PERU IL
61354-0036
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-7400
  • Fax: 815-223-7477
Mailing address:
  • Phone: 815-223-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036100858
License Number StateIL

VIII. Authorized Official

Name: KAMAL KISHORE
Title or Position: PRESIDENT
Credential: MD
Phone: 815-223-7400