Provider Demographics
NPI:1881754570
Name:NORTHEWESTERN OPTHALMIC INSTITUTE
Entity type:Organization
Organization Name:NORTHEWESTERN OPTHALMIC INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOURNIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-832-3900
Mailing Address - Street 1:3633 WEST LAKE AVENUE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026
Mailing Address - Country:US
Mailing Address - Phone:847-832-3900
Mailing Address - Fax:847-832-3904
Practice Address - Street 1:3633 WEST LAKE AVENUE
Practice Address - Street 2:SUITE 104
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026
Practice Address - Country:US
Practice Address - Phone:847-832-3900
Practice Address - Fax:847-832-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36093343207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7797487OtherAETNA
IL036093343Medicaid
IL036093343Medicaid
IL036093343Medicaid
IL=========OtherTAX ID
ILDC3777Medicare ID - Type UnspecifiedRAILROAD MEDICARE