Basic Information
| Provider Information | |||||||||
| NPI: | 1043648439 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KERATOCONUS SPECIALIST OF ILLINOIS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 S WAUKEGAN RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600155653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474120315 | ||||||||
| FaxNumber: | 8474120316 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 WESTBROOK CORPORATE CTR | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085624682 | ||||||||
| FaxNumber: | 7085624785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2013 | ||||||||
| LastUpdateDate: | 10/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | EIDEN | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8474120311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 046007419 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
No ID Information.