Provider Demographics
NPI:1598762007
Name:OLYMPIA FIELDS EYECARE, LTD.
Entity Type:Organization
Organization Name:OLYMPIA FIELDS EYECARE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:S
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-957-1618
Mailing Address - Street 1:19740 GOVERNORS HWY STE 124
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2085
Mailing Address - Country:US
Mailing Address - Phone:708-957-1618
Mailing Address - Fax:708-748-7305
Practice Address - Street 1:19740 GOVERNORS HWY STE 124
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2085
Practice Address - Country:US
Practice Address - Phone:708-748-5202
Practice Address - Fax:708-748-7305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042007134207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078950Medicaid
IL0630600001Medicare NSC