=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578713780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINAS A. SIDRYS M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2008
-----------------------------------------------------
Last Update Date | 10/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 WESTGATE PLZ
-----------------------------------------------------
City | STREATOR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61364-2767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-672-4018
-----------------------------------------------------
Fax | 815-672-5160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 WESTGATE PLZ
-----------------------------------------------------
City | STREATOR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61364-2767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-672-4018
-----------------------------------------------------
Fax | 815-672-5160
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LINAS A SIDRYS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 815-672-4018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------