Basic Information
Provider Information | |||||||||
NPI: | 1144288689 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VISION SURGEONS AND CONSULTANTS, LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5501 W 79TH ST | ||||||||
Address2: | SUITE 400 | ||||||||
City: | BURBANK | ||||||||
State: | IL | ||||||||
PostalCode: | 604591784 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7738844523 | ||||||||
FaxNumber: | 7738844580 | ||||||||
Practice Location | |||||||||
Address1: | 800 AUSTIN ST | ||||||||
Address2: | EAST TOWER STE 151 | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602023439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8473282300 | ||||||||
FaxNumber: | 8474921988 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 10/21/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOLDEN-BRENNER | ||||||||
AuthorizedOfficialFirstName: | CARRIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8473282300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 01623637 | 01 | IL | BLUE SHIELD | OTHER |