Provider Demographics
NPI:1578643698
Name:BOLINGBROOK EYE SPECIALISTS LTD
Entity Type:Organization
Organization Name:BOLINGBROOK EYE SPECIALISTS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-968-9440
Mailing Address - Street 1:150 CONCORD LANE
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440
Mailing Address - Country:US
Mailing Address - Phone:630-759-1330
Mailing Address - Fax:630-968-0180
Practice Address - Street 1:150 CONCORD LANE
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440
Practice Address - Country:US
Practice Address - Phone:630-759-1330
Practice Address - Fax:630-968-0180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007060152W00000X
IL346000246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007060Medicaid
IL208751Medicare ID - Type Unspecified
0531030001Medicare NSC
IL208406Medicare ID - Type Unspecified
T37392Medicare UPIN
IL046007060Medicaid