Provider Demographics
NPI:1003875436
Name:ILLINOIS RETINA INSTITUTE, SC
Entity Type:Organization
Organization Name:ILLINOIS RETINA INSTITUTE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KISHORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-223-7400
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-0036
Mailing Address - Country:US
Mailing Address - Phone:815-223-7400
Mailing Address - Fax:
Practice Address - Street 1:3602 MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1450
Practice Address - Country:US
Practice Address - Phone:815-223-7400
Practice Address - Fax:815-223-7477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100858207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100858Medicaid
IL036100858Medicaid
IL204115Medicare PIN