Provider Demographics
NPI:1083803050
Name:FOREMAN & STACK OD PC
Entity Type:Organization
Organization Name:FOREMAN & STACK OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-469-2418
Mailing Address - Street 1:876 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137
Mailing Address - Country:US
Mailing Address - Phone:630-469-2418
Mailing Address - Fax:630-469-4680
Practice Address - Street 1:876 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137
Practice Address - Country:US
Practice Address - Phone:630-469-2418
Practice Address - Fax:630-469-4680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA046007804152W00000X
IL046007804152W00000X
IL046007738152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209576Medicare UPIN