Provider Demographics
NPI:1164464509
Name:ADVANCED EYECARE GROUP PC
Entity Type:Organization
Organization Name:ADVANCED EYECARE GROUP PC
Other - Org Name:DRS JESSEN WESLEY AND ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:O'HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-848-3900
Mailing Address - Street 1:7011 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1001
Mailing Address - Country:US
Mailing Address - Phone:708-848-3900
Mailing Address - Fax:708-848-3997
Practice Address - Street 1:7011 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1001
Practice Address - Country:US
Practice Address - Phone:708-848-3900
Practice Address - Fax:708-848-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00173468OtherRAILROAD MEDICARE
IL0001616047OtherBLUE CROSS BLUE SHIELD
ILP00173468OtherRAILROAD MEDICARE
IL565980Medicare PIN