Provider Demographics
NPI:1417123803
Name:PROFESSIONAL EYE CENTER, PC
Entity Type:Organization
Organization Name:PROFESSIONAL EYE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MPH
Authorized Official - Phone:773-363-9447
Mailing Address - Street 1:1517 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4509
Mailing Address - Country:US
Mailing Address - Phone:773-363-9447
Mailing Address - Fax:773-363-9675
Practice Address - Street 1:1517 E 53RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4509
Practice Address - Country:US
Practice Address - Phone:773-363-9447
Practice Address - Fax:773-363-9675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008653Medicaid
IL394990Medicare UPIN