Provider Demographics
NPI:1710924857
Name:PEDIATRIC EYE ASSOCIATES, PC
Entity Type:Organization
Organization Name:PEDIATRIC EYE ASSOCIATES, PC
Other - Org Name:PEDIATRIC EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-256-2020
Mailing Address - Street 1:3612 LAKE AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3612 LAKE AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1000
Practice Address - Country:US
Practice Address - Phone:847-256-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
588170Medicare PIN
588170Medicare PIN