MEDICARE: RETINA CENTER OF CHICAGO PLLC

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	207WX0107X	Retina Specialist (Ophthalmology) Physician
2	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1851126270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RETINA CENTER OF CHICAGO PLLC

Provider Business Mailing Address
First Line	:	PO BOX 737505
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-7505
Country	:	US
Telephone Number	:	773-943-7425
Fax Number	:	773-896-0303

Provider Business Practice Location Address
First Line	:	477 E BUTTERFIELD RD STE 105
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-5622
Country	:	US
Telephone Number	:	773-943-7425
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRIAN LARSEN
Credential	:	MD
Telephone Number	:	773-943-7425

Provider Enumeration Date	:	09/05/2024
Last Update Date	:	05/18/2026

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