=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316272289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WYSE EYECARE SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2009
-----------------------------------------------------
Last Update Date | 01/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 SKOKIE BLVD SUITE 150
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-497-2020
-----------------------------------------------------
Fax | 847-497-2002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 SKOKIE BLVD SUITE 150
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-497-2020
-----------------------------------------------------
Fax | 847-497-2002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TAMARA B WYSE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-497-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 036092731
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------