Provider Demographics
NPI:1235275652
Name:SUBURBAN OPTOMETRIC GROUP, P.C.
Entity Type:Organization
Organization Name:SUBURBAN OPTOMETRIC GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ZAHARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-349-2600
Mailing Address - Street 1:10001 W 143RD ST
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2026
Mailing Address - Country:US
Mailing Address - Phone:708-349-2600
Mailing Address - Fax:
Practice Address - Street 1:10001 W 143RD ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2026
Practice Address - Country:US
Practice Address - Phone:708-349-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUBURBAN OPTOMETRIC GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-30
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.007985152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDA8522OtherRR MEDICARE GROUP
IL0=========OtherTAX ID ORLAND PK
IL1148260001Medicare NSC
IL985800Medicare ID - Type Unspecified
ILDA8522OtherRR MEDICARE GROUP