MEDICARE: OPHTHALMIC SPECIALISTS GROUP, LLC

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	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1740380336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPHTHALMIC SPECIALISTS GROUP, LLC

Provider Business Mailing Address
First Line	:	18440 GOVERNORS HWY
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-2911
Country	:	US
Telephone Number	:	708-798-2191
Fax Number	:

Provider Business Practice Location Address
First Line	:	18440 GOVERNORS HWY
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-2911
Country	:	US
Telephone Number	:	708-798-2191
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	RACHEL GENA
Credential	:
Telephone Number	:	708-798-2191

Provider Enumeration Date	:	09/23/2006
Last Update Date	:	05/23/2012

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