Provider Demographics
NPI:1194055525
Name:ANNMARIE SURDICH-PITRA OD PC
Entity type:Organization
Organization Name:ANNMARIE SURDICH-PITRA OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SURDICH-PITRA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-541-3169
Mailing Address - Street 1:1712 OGDEN AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1230
Mailing Address - Country:US
Mailing Address - Phone:630-541-3169
Mailing Address - Fax:630-541-5140
Practice Address - Street 1:1712 OGDEN AVE STE D
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1230
Practice Address - Country:US
Practice Address - Phone:630-541-3169
Practice Address - Fax:630-541-5140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL047935871302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3604Medicare PIN