Provider Demographics
NPI:1043648439
Name:KERATOCONUS SPECIALIST OF ILLINOIS LTD
Entity Type:Organization
Organization Name:KERATOCONUS SPECIALIST OF ILLINOIS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:EIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-412-0311
Mailing Address - Street 1:360 S WAUKEGAN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5653
Mailing Address - Country:US
Mailing Address - Phone:847-412-0315
Mailing Address - Fax:847-412-0316
Practice Address - Street 1:4 WESTBROOK CORPORATE CTR
Practice Address - Street 2:SUITE 111
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5752
Practice Address - Country:US
Practice Address - Phone:708-562-4682
Practice Address - Fax:708-562-4785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007419152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38534Medicare UPIN