Basic Information
Provider Information | |||||||||
NPI: | 1396749008 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDICAL EYE SERVICES, LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 48 S GREENLEAF ST | ||||||||
Address2: |   | ||||||||
City: | GURNEE | ||||||||
State: | IL | ||||||||
PostalCode: | 600313300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476624016 | ||||||||
FaxNumber: | 8476624174 | ||||||||
Practice Location | |||||||||
Address1: | 48 S GREENLEAF ST | ||||||||
Address2: |   | ||||||||
City: | GURNEE | ||||||||
State: | IL | ||||||||
PostalCode: | 600313300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476624016 | ||||||||
FaxNumber: | 8476624174 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOSKINS | ||||||||
AuthorizedOfficialFirstName: | SYLVIA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | INSURANCE COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 8476624016 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X |   | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 4915051 | 01 | IL | BLUE CROSS BLUE SHIELD ID | OTHER |