Basic Information
| Provider Information | |||||||||
| NPI: | 1821049693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES OVITSKY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 W PETERSON AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606593306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735883090 | ||||||||
| FaxNumber: | 7735883210 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 W PETERSON AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606593306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735883090 | ||||||||
| FaxNumber: | 7735883210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | OVITSKY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7735883090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046007650 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | CJ0861 | 01 | IL | RR MCR GROUP | OTHER | 0001604768 | 01 | IL | BLUE CROSS & BLUE SHIELD | OTHER |