MEDICARE: TERESA BETH EIDE O.D.

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	591	SD
2	152W00000X	Optometrist		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	:	1487605762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA BETH EIDE O.D.

Provider Business Mailing Address
First Line	:	1423 W FILLMORE ST # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4615
Country	:	US
Telephone Number	:	773-321-6668
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 BROADVIEW VILLAGE SQ
Second Line	:
City	:	BROADVIEW
State	:	IL
Zip	:	60155-4874
Country	:	US
Telephone Number	:	708-343-2099
Fax Number	:

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	12/11/2007

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Directions to “ TERESA BETH EIDE O.D.” Practice Location

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