=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285457143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEAMVISION MSO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2024
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 W CALENDAR AVE
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60525-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-354-0500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6235 CERMAK RD
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-354-0500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | TILLIE ANDRADE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-449-9173
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0132X
-----------------------------------------------------
Taxonomy Name | Ophthalmologic Surgery Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------