Provider Demographics
NPI:1760604425
Name:SULLIVAN OSTOICH EYE CARE LTD
Entity Type:Organization
Organization Name:SULLIVAN OSTOICH EYE CARE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:G
Authorized Official - Last Name:OSTOICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-631-2980
Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:#300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-631-2980
Mailing Address - Fax:773-631-2842
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:#300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-631-2980
Practice Address - Fax:773-631-2842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211518Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER