MEDICARE: THADDEUS, 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	060-0005772	IL

General Provider Information

NPI Number	:	1831120005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THADDEUS, LTD

Provider Business Mailing Address
First Line	:	4017 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1834
Country	:	US
Telephone Number	:	773-545-2660
Fax Number	:

Provider Business Practice Location Address
First Line	:	4017 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1834
Country	:	US
Telephone Number	:	773-545-2660
Fax Number	:	773-327-3015

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	DR. SPENCER PAUL VIDULICH
Credential	:	O.D.
Telephone Number	:	773-327-3000

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	11/12/2009

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