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General NPI Number Information
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NPI Number | 1639302383
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Entity Type | Organization
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Legal Business Name | SOUTHPORT EYE ASSOCIATES LTD
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Dates
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Enumeration Date | 08/28/2009
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Last Update Date | 05/24/2018
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Provider Practice Location Address
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Address Line | 3539 N SOUTHPORT AVE
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City | CHICAGO
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State | IL
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Zip | 60657
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Country | US
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Telephone | 773-871-2020
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Fax | 773-871-2099
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Provider Business Mailing Address
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Address Line | 3539 N SOUTHPORT AVE
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City | CHICAGO
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State | IL
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Zip | 60657-6447
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Country | US
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Telephone | 773-871-2020
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Fax | 773-871-2099
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. MICHAEL SCULLEY
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Credential | OD
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Telephone | 773-871-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046.009541
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License Number State | IL
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