Provider Demographics
NPI:1225038870
Name:ILLINOIS RETINA ASSOCIATES PLLC
Entity Type:Organization
Organization Name:ILLINOIS RETINA ASSOCIATES PLLC
Other - Org Name:THE RETINA CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-915-6963
Mailing Address - Street 1:11516 183RD PL STE SW
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-9471
Mailing Address - Country:US
Mailing Address - Phone:708-877-1300
Mailing Address - Fax:708-596-8719
Practice Address - Street 1:71 W 156TH ST
Practice Address - Street 2:STE 400
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4265
Practice Address - Country:US
Practice Address - Phone:708-596-8710
Practice Address - Fax:708-596-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2022-12-09
Deactivation Date:2018-05-16
Deactivation Code:
Reactivation Date:2018-05-18
Provider Licenses
StateLicense IDTaxonomies
IL036113707207W00000X
207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCN0205OtherRAILROAD MEDICARE
ILCN1137OtherRAILROAD MEDICARE
INCN0205OtherRAILROAD MEDICARE
ILCN1137OtherRAILROAD MEDICARE
IL532050Medicare PIN