Provider Demographics
NPI:1710033352
Name:SUBURBAN RETINA LTD
Entity Type:Organization
Organization Name:SUBURBAN RETINA LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:VIERLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-424-9877
Mailing Address - Street 1:130 S MAIN ST
Mailing Address - Street 2:STE 303
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2670
Mailing Address - Country:US
Mailing Address - Phone:630-424-9877
Mailing Address - Fax:630-424-9878
Practice Address - Street 1:130 S MAIN ST
Practice Address - Street 2:STE 303
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2670
Practice Address - Country:US
Practice Address - Phone:630-424-9877
Practice Address - Fax:630-424-9878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-091886207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF59347Medicare UPIN
IL210926Medicare ID - Type Unspecified