MEDICARE: SOUTHPORT EYE ASSOCIATES LTD

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	046.009541	IL

General Provider Information

NPI Number	:	1639302383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHPORT EYE ASSOCIATES LTD

Provider Business Mailing Address
First Line	:	3539 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-6447
Country	:	US
Telephone Number	:	773-871-2020
Fax Number	:	773-871-2099

Provider Business Practice Location Address
First Line	:	3539 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657
Country	:	US
Telephone Number	:	773-871-2020
Fax Number	:	773-871-2099

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. MICHAEL SCULLEY
Credential	:	OD
Telephone Number	:	773-871-2020

Provider Enumeration Date	:	08/28/2009
Last Update Date	:	05/24/2018

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