Provider Demographics
NPI:1528238854
Name:FOX VALLEY OPHTHALMOLOGY
Entity type:Organization
Organization Name:FOX VALLEY OPHTHALMOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-584-9850
Mailing Address - Street 1:750 FLETCHER DR STE 106
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4703
Mailing Address - Country:US
Mailing Address - Phone:847-695-0499
Mailing Address - Fax:847-695-4339
Practice Address - Street 1:40W330 LAFOX RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6515
Practice Address - Country:US
Practice Address - Phone:630-584-9850
Practice Address - Fax:630-584-1523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042002501207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCL1986OtherMEDICARE RAILROAD
IL04519570OtherBCBS
IL379827OtherUNITED HEALTHCARE
IL379827OtherUNITED HEALTHCARE
ILCL1986OtherMEDICARE RAILROAD