Provider Demographics
NPI:1194711655
Name:RETINA VITREOUS ASSOCIATES, PC
Entity type:Organization
Organization Name:RETINA VITREOUS ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:D
Authorized Official - Last Name:PELZEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-424-8855
Mailing Address - Street 1:4930 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2504
Mailing Address - Country:US
Mailing Address - Phone:708-424-8855
Mailing Address - Fax:
Practice Address - Street 1:4930 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2504
Practice Address - Country:US
Practice Address - Phone:708-424-8855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL660092Medicare ID - Type Unspecified
IL660093Medicare PIN