=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992996383
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN RENEE PETROCZKY O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2007
-----------------------------------------------------
Last Update Date | 07/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 363 S RANDALL RD ELGIN FAMILY EYE CARE
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-5526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-888-1555
-----------------------------------------------------
Fax | 847-888-2508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 178 LONGFORD DR
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60120-4688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-291-7647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046.009976
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------