Provider Demographics
NPI:1295032761
Name:DR. RICHARD SUROWIAK INC
Entity Type:Organization
Organization Name:DR. RICHARD SUROWIAK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUROWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-459-4074
Mailing Address - Street 1:6219 NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7932
Mailing Address - Country:US
Mailing Address - Phone:815-459-4017
Mailing Address - Fax:
Practice Address - Street 1:6219 NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7932
Practice Address - Country:US
Practice Address - Phone:815-459-4017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty