Basic Information
| Provider Information | |||||||||
| NPI: | 1356413223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAETHER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOUCHER | ||||||||
| OtherFirstName: | KELLY | ||||||||
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| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 680 N LAKE SHORE DR STE 1000 | ||||||||
| Address2: | ATTN: MARTHA HOLDER | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606118709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472950001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1475 E BELVIDERE RD STE 1297 | ||||||||
| Address2: | NORTHWESTERN OPHTHALMOLOGY DEPARTMENT | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600302026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472950001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046-009772 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1578798989 | 01 | NPI | OTHER |