1518181304 NPI number — EYE CARE CENTER OF LAKE COUNTY REFRACTIVE SURGERY ASSOCIATES

Table of content: (NPI 1518181304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518181304 NPI number — EYE CARE CENTER OF LAKE COUNTY REFRACTIVE SURGERY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CARE CENTER OF LAKE COUNTY REFRACTIVE SURGERY ASSOCIATES
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:
1518181304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2424 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUKEGAN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60085-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-244-1657
Provider Business Mailing Address Fax Number:
847-244-5122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 E PHILLIP RD
Provider Second Line Business Practice Location Address:
SUITE 1110
Provider Business Practice Location Address City Name:
VERNON HILLS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60061-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-244-1657
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MERKT
Authorized Official First Name:
JANICE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
847-244-1657

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04915265 . This is a "BLUE CROSS - BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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