Provider Demographics
NPI:1982886883
Name:SUBURBAN EYES CLINIC, LLC
Entity Type:Organization
Organization Name:SUBURBAN EYES CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-424-1100
Mailing Address - Street 1:500 DAVIS ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4668
Mailing Address - Country:US
Mailing Address - Phone:847-424-1100
Mailing Address - Fax:847-864-6138
Practice Address - Street 1:500 DAVIS ST
Practice Address - Street 2:SUITE 810
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4668
Practice Address - Country:US
Practice Address - Phone:847-424-1100
Practice Address - Fax:847-864-6138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107379207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216012Medicare PIN
IL216013Medicare PIN