Provider Demographics
NPI:1942483664
Name:NORTHERN ILLINOIS RETINA LTD
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS RETINA LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-226-4990
Mailing Address - Street 1:1235 N MULFORD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-226-4990
Mailing Address - Fax:815-226-9472
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-226-4990
Practice Address - Fax:815-226-9472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042006794207W00000X
IL036073359207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1942483664OtherNPI
IL1942483664OtherNPI