Provider Demographics
NPI:1629064514
Name:WALTER I. FRIED PH.D., M.D., S.C.
Entity Type:Organization
Organization Name:WALTER I. FRIED PH.D., M.D., S.C.
Other - Org Name:SUREVISION EYE CENTERS OF LAKE COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHRINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-249-4660
Mailing Address - Street 1:3477 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3734
Mailing Address - Country:US
Mailing Address - Phone:847-249-4660
Mailing Address - Fax:847-249-4950
Practice Address - Street 1:3477 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3734
Practice Address - Country:US
Practice Address - Phone:847-249-4660
Practice Address - Fax:847-249-4950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1024130001Medicare NSC
IL246952Medicare ID - Type UnspecifiedMEDICARE GROUP #