Provider Demographics
NPI:1164569380
Name:RETINAL VITREAL CONSULTANTS LTD
Entity Type:Organization
Organization Name:RETINAL VITREAL CONSULTANTS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ITTIARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-567-2795
Mailing Address - Street 1:PO BOX 166516
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-6516
Mailing Address - Country:US
Mailing Address - Phone:312-567-2795
Mailing Address - Fax:800-707-4890
Practice Address - Street 1:2600 S MICHIGAN AVE
Practice Address - Street 2:STE 212
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2859
Practice Address - Country:US
Practice Address - Phone:312-567-2795
Practice Address - Fax:800-707-4890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164563980OtherNPI
IL01624740OtherBLUE CROSS BLUE SHIELD