MEDICARE: PROFESSIONAL EYE CENTER, PC

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	046008653	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417123803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL EYE CENTER, PC

Provider Business Mailing Address
First Line	:	1517 E 53RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4509
Country	:	US
Telephone Number	:	773-363-9447
Fax Number	:	773-363-9675

Provider Business Practice Location Address
First Line	:	1517 E 53RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4509
Country	:	US
Telephone Number	:	773-363-9447
Fax Number	:	773-363-9675

Authorized Official
Title or Position	:	PRESIDENT/ OPTOMETRIST
Name	:	DR. JEANIE C. WASHINGTON
Credential	:	O.D., M.P.H.
Telephone Number	:	773-363-9447

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	06/24/2009

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