Provider Demographics
NPI:1841842549
Name:2020 ILLINOIS PC
Entity type:Organization
Organization Name:2020 ILLINOIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-880-6066
Mailing Address - Street 1:33 ARCH ST FL 17
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1047 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-6332
Practice Address - Country:US
Practice Address - Phone:617-356-8117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376644831OtherNPI TYPE 1