MEDICARE: SENIOR EYE ASSOCIATES SC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1622243	OTHER	IL	BCBS IL GROUP NUMBER

General Provider Information

NPI Number	:	1316088305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIOR EYE ASSOCIATES SC

Provider Business Mailing Address
First Line	:	PO BOX 2354
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60065-2354
Country	:	US
Telephone Number	:	773-792-1011
Fax Number	:	773-889-0224

Provider Business Practice Location Address
First Line	:	6601 N AVONDALE AVE STE 102
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-1567
Country	:	US
Telephone Number	:	773-792-1011
Fax Number	:	773-889-0224

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RYAN CHRISTOPHER BARNES
Credential	:	O.D.
Telephone Number	:	773-792-1011

Provider Enumeration Date	:	02/10/2007
Last Update Date	:	02/21/2023

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