Basic Information
| Provider Information | |||||||||
| NPI: | 1356464952 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNETH J. LOSSMAN, O.D., P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LOSSMAN EYE CARE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 950 WEST MAIN ST | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | LAKE ZURICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477262020 | ||||||||
| FaxNumber: | 8477262036 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 W MAIN ST | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | LAKE ZURICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600473417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477262020 | ||||||||
| FaxNumber: | 8477262036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 04/09/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOSSMAN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8477262020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046006871 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | CD3263 | 01 | IL | RAILROAD MEDICARE | OTHER | 1356464952 | 05 | IL | MEDICAID |