Healthcare Provider Details

I. General information

NPI: 1013342401
Provider Name (Legal Business Name): NORTH SHORE EYE AND VASCULAR SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 E IRVING PARK RD
WOOD DALE IL
60191-2099
US

IV. Provider business mailing address

236 E IRVING PARK RD
WOOD DALE IL
60191-2099
US

V. Phone/Fax

Practice location:
  • Phone: 847-590-1500
  • Fax: 847-590-1502
Mailing address:
  • Phone: 847-590-1500
  • Fax: 847-590-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036049793
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036067328
License Number StateIL

VIII. Authorized Official

Name: DOMINIC TOLITANO
Title or Position: OWNER
Credential: M.D.
Phone: 847-590-1500