Provider Demographics
NPI:1821175498
Name:CERMAK OPTICAL, INC
Entity Type:Organization
Organization Name:CERMAK OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-788-2400
Mailing Address - Street 1:7120 CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2153
Mailing Address - Country:US
Mailing Address - Phone:708-788-2400
Mailing Address - Fax:708-788-3472
Practice Address - Street 1:7120 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2153
Practice Address - Country:US
Practice Address - Phone:708-788-2400
Practice Address - Fax:708-788-3472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL28154982332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1152970001Medicare ID - Type UnspecifiedADMINISTAR FEDERAL ID