MEDICARE: SHORELAND OPTICAL CO #27 INC.

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	IL046007178	IL

General Provider Information

NPI Number	:	1508986175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHORELAND OPTICAL CO #27 INC.

Provider Business Mailing Address
First Line	:	3136 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3117
Country	:	US
Telephone Number	:	773-871-8210
Fax Number	:

Provider Business Practice Location Address
First Line	:	3136 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3117
Country	:	US
Telephone Number	:	773-871-8210
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RALPH GEIDERMAN
Credential	:	O.D.
Telephone Number	:	773-871-8210

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	12/17/2014

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