Provider Demographics
NPI:1417037623
Name:RETINA INSTITUTE OF ILLINOIS
Entity Type:Organization
Organization Name:RETINA INSTITUTE OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:YOUNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-297-8900
Mailing Address - Street 1:8780 W GOLF RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-5602
Mailing Address - Country:US
Mailing Address - Phone:847-297-8900
Mailing Address - Fax:847-297-8926
Practice Address - Street 1:8780 W GOLF RD
Practice Address - Street 2:SUITE 304
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-5602
Practice Address - Country:US
Practice Address - Phone:847-297-8900
Practice Address - Fax:847-297-8926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2143430032Medicare PIN
IL214343Medicare PIN
IL214342002Medicare PIN
IL214342001Medicare PIN
ILK32480Medicare PIN
IL214342Medicare PIN
ILK32482Medicare PIN
IL214343002Medicare PIN
IL214343001Medicare PIN