Provider Demographics
NPI:1356413223
Name:RAETHER, KELLY (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RAETHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:680 N LAKE SHORE DR STE 1000
Mailing Address - Street 2:ATTN: MARTHA HOLDER
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8709
Mailing Address - Country:US
Mailing Address - Phone:847-295-0001
Mailing Address - Fax:
Practice Address - Street 1:1475 E BELVIDERE RD STE 1297
Practice Address - Street 2:NORTHWESTERN OPHTHALMOLOGY DEPARTMENT
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2026
Practice Address - Country:US
Practice Address - Phone:847-295-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009772152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578798989OtherNPI
ILV06656Medicare UPIN
999570Medicare PIN