Provider Demographics
NPI:1316065881
Name:GLEN ELLYN OPHTHALMOLOGY ASSOCIATES, LTD.
Entity type:Organization
Organization Name:GLEN ELLYN OPHTHALMOLOGY ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-858-4660
Mailing Address - Street 1:45 S PARK BLVD
Mailing Address - Street 2:SUITE 375
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6280
Mailing Address - Country:US
Mailing Address - Phone:630-858-4660
Mailing Address - Fax:630-858-9511
Practice Address - Street 1:45 S PARK BLVD
Practice Address - Street 2:SUITE 375
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6280
Practice Address - Country:US
Practice Address - Phone:630-858-4660
Practice Address - Fax:630-858-9511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCB0740OtherRAILROAD MEDICARE
ILCB0740OtherRAILROAD MEDICARE
IL0888960001Medicare NSC
ILCB0740Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IL=========6013702Medicaid