MEDICARE: DR. KEITH ALAN MIHALY OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046007845	IL
2	152W00000X	Optometrist	OPC002198	FL
3	152W00000X	Optometrist	18002176A	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0410048631	OTHER	IL	MEDICARE ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	5303296	OTHER	IL	AETNA
3	1605476	OTHER	IL	BLUE CROSS BLUE SHIELD IL
4	363614738	OTHER	IL	TAX ID
5	363614738	OTHER	IL	CIGNA

General Provider Information

NPI Number	:	1154384709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH ALAN MIHALY OD

Provider Business Mailing Address
First Line	:	400 W DUNDEE RD
Second Line	:	SUITE 14-15
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-3415
Country	:	US
Telephone Number	:	847-459-9119
Fax Number	:	847-459-8115

Provider Business Practice Location Address
First Line	:	400 W DUNDEE RD
Second Line	:	SUITE 14-15
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-3415
Country	:	US
Telephone Number	:	847-459-9119
Fax Number	:	847-459-8115

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/02/2008

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Directions to “ DR. KEITH ALAN MIHALY OD” Practice Location

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