Provider Demographics
NPI:1629371067
Name:ID CHICAGO INC
Entity Type:Organization
Organization Name:ID CHICAGO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ARTIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-755-4343
Mailing Address - Street 1:3337 N HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2694
Mailing Address - Country:US
Mailing Address - Phone:773-755-4343
Mailing Address - Fax:
Practice Address - Street 1:3337 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2694
Practice Address - Country:US
Practice Address - Phone:773-755-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046 8255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1780739862OtherPERSONAL NPI NUMBER