Provider Demographics
NPI:1720590375
Name:GLAUCOMA ASSOCIATES OF ILLINOIS LLC
Entity Type:Organization
Organization Name:GLAUCOMA ASSOCIATES OF ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AZIZUR
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-543-6865
Mailing Address - Street 1:201 E CHESTNUT ST APT 9A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-7376
Mailing Address - Country:US
Mailing Address - Phone:630-242-6500
Mailing Address - Fax:815-399-5543
Practice Address - Street 1:695 N PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6225
Practice Address - Country:US
Practice Address - Phone:630-929-3034
Practice Address - Fax:815-399-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-03
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129423207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01320105OtherRAILROAD MEDICARE
IL036129423Medicaid