Provider Demographics
NPI:1760666754
Name:ADVANCED RETINAL INSTITUTE, INC.
Entity Type:Organization
Organization Name:ADVANCED RETINAL INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-499-0123
Mailing Address - Street 1:7808 W COLLEGE DR
Mailing Address - Street 2:1NW
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1027
Mailing Address - Country:US
Mailing Address - Phone:708-499-0123
Mailing Address - Fax:708-499-0611
Practice Address - Street 1:7808 W COLLEGE DR
Practice Address - Street 2:1NW
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1027
Practice Address - Country:US
Practice Address - Phone:708-499-0123
Practice Address - Fax:708-499-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111343207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111343Medicaid
IL216010OtherPTAN
IL217046046Medicaid
IL1760666754OtherNPI
IL036111343Medicaid