Basic Information
| Provider Information | |||||||||
| NPI: | 1578636825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE EYE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2914 CENTRAL ST | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478644768 | ||||||||
| FaxNumber: | 8478644795 | ||||||||
| Practice Location | |||||||||
| Address1: | 2914 CENTRAL ST | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478644768 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | KNIGHT | ||||||||
| AuthorizedOfficialFirstName: | MILLICENT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 8478644768 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 152W00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 01635011 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |