Provider Demographics
NPI:1619936358
Name:WEST SUBURBAN EYE CENTER, S.C.
Entity Type:Organization
Organization Name:WEST SUBURBAN EYE CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRAKASH
Authorized Official - Middle Name:
Authorized Official - Last Name:SELVARAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-759-9800
Mailing Address - Street 1:396 REMINGTON BLVD.
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-3442
Mailing Address - Country:US
Mailing Address - Phone:630-759-9800
Mailing Address - Fax:630-759-9858
Practice Address - Street 1:396 REMINGTON BLVD.
Practice Address - Street 2:SUITE 340
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3442
Practice Address - Country:US
Practice Address - Phone:630-759-9800
Practice Address - Fax:630-759-9858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095872207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6044001Medicaid
IL205810Medicare ID - Type Unspecified
IL=========6044001Medicaid