Provider Demographics
NPI:1669945440
Name:EYE SPECIALIST GROUP, LLC
Entity type:Organization
Organization Name:EYE SPECIALIST GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIOLETTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-307-0217
Mailing Address - Street 1:4400 W 95TH ST STE 312
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2660
Mailing Address - Country:US
Mailing Address - Phone:708-307-0217
Mailing Address - Fax:
Practice Address - Street 1:4400 W 95TH ST STE 312
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2660
Practice Address - Country:US
Practice Address - Phone:708-307-0217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036066839OtherPHYSICIAN LICENSE