Provider Demographics
NPI:1619129491
Name:CHICAGO RETINA, INCORPORATED
Entity Type:Organization
Organization Name:CHICAGO RETINA, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-394-6990
Mailing Address - Street 1:1182 N MILWAUKEE AVE
Mailing Address - Street 2:STOREFRONT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-4007
Mailing Address - Country:US
Mailing Address - Phone:773-394-6990
Mailing Address - Fax:773-394-6993
Practice Address - Street 1:1182 N MILWAUKEE AVE
Practice Address - Street 2:STOREFRONT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-4007
Practice Address - Country:US
Practice Address - Phone:773-394-6990
Practice Address - Fax:773-394-6993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-11
Last Update Date:2008-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097549207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty