Basic Information
| Provider Information | |||||||||
| NPI: | 1851692644 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NIERMAN VISION CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NIERMAN VISION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 243 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606101236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123371126 | ||||||||
| FaxNumber: | 3123371609 | ||||||||
| Practice Location | |||||||||
| Address1: | 243 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606101236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123371126 | ||||||||
| FaxNumber: | 3123371609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2010 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NIERMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3123371126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | MN1954608 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 99301 | 01 | IL | WPS SUBMITTER NUMBER | OTHER | IL8498 | 01 | IL | MEDICARE PTAN | OTHER |