=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881694933
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN S POLLACK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2005
-----------------------------------------------------
Last Update Date | 02/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 BARNEY DR STE D
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435-5279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-744-7515
-----------------------------------------------------
Fax | 815-744-7661
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11516 183RD PL STE SW
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60467-9471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-877-1300
-----------------------------------------------------
Fax | 708-596-8719
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number | 036096324
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 036096324
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------