1316088305 NPI number — SENIOR EYE ASSOCIATES SC

Table of content: (NPI 1316088305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316088305 NPI number — SENIOR EYE ASSOCIATES SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENIOR EYE ASSOCIATES SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316088305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2354
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60065-2354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-792-1011
Provider Business Mailing Address Fax Number:
773-889-0224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6601 N AVONDALE AVE STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60631-1567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-792-1011
Provider Business Practice Location Address Fax Number:
773-889-0224
Provider Enumeration Date:
02/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BARNES
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-792-1011

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1622243 . This is a "BCBS IL GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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