Provider Demographics
NPI:1285612390
Name:ILLINOIS COLLEGE OF OPTOMETRY
Entity type:Organization
Organization Name:ILLINOIS COLLEGE OF OPTOMETRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:COLIP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:312-949-7701
Mailing Address - Street 1:3241 S MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3878
Mailing Address - Country:US
Mailing Address - Phone:312-225-6200
Mailing Address - Fax:312-949-7660
Practice Address - Street 1:3241 S MICHIGAN AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3878
Practice Address - Country:US
Practice Address - Phone:312-225-6200
Practice Address - Fax:312-949-7660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
IL8720518332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL502720OtherMEDICARE PTAN
ILCD4768OtherRAILROAD MEDICARE
IL=========Medicaid
IL0534840001Medicare NSC
IL502720OtherMEDICARE PTAN