Basic Information
| Provider Information | |||||||||
| NPI: | 1578829867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDUSTRIAL OPTICAL SERVICE, INC | ||||||||
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| OtherOrganizationName: | SPEX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 SOUTH LASALLE STREET | ||||||||
| Address2: | 27TH FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60603 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5408 N CLARK ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606401210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732752020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2012 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | ROITSTEIN | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3126737192 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1636706 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 8825444 | 01 | IL | MULTIPLAN | OTHER | 7235044 | 01 | IL | AETNA | OTHER |