MEDICARE: ILLINOIS 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	046-009714	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE7499	OTHER		RAILROAD MEDICARE

General Provider Information

NPI Number	:	1770660441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLINOIS EYE ASSOCIATES LTD

Provider Business Mailing Address
First Line	:	540 W NORTH ST
Second Line	:	SUITE 209
City	:	MANHATTAN
State	:	IL
Zip	:	60442-8201
Country	:	US
Telephone Number	:	815-478-0100
Fax Number	:	815-478-9100

Provider Business Practice Location Address
First Line	:	540 W NORTH ST
Second Line	:	SUITE 209
City	:	MANHATTAN
State	:	IL
Zip	:	60442-8201
Country	:	US
Telephone Number	:	815-478-0100
Fax Number	:	815-478-9100

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEFFREY M PIETRZYK
Credential	:	O.D.
Telephone Number	:	815-478-0100

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	09/17/2012

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