Provider Demographics
NPI:1588727663
Name:GLEN ELLYN VISION CENTER PC
Entity type:Organization
Organization Name:GLEN ELLYN VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIKORSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-469-4141
Mailing Address - Street 1:440 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5124
Mailing Address - Country:US
Mailing Address - Phone:630-469-4141
Mailing Address - Fax:630-469-2015
Practice Address - Street 1:440 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5124
Practice Address - Country:US
Practice Address - Phone:630-469-4141
Practice Address - Fax:630-469-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.006197152WC0802X, 152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU82851Medicare UPIN
IL651040Medicare ID - Type UnspecifiedDR MARTIN SIKORSKI
IL0449300001Medicare NSC
ILU52073Medicare UPIN
IL354800Medicare ID - Type UnspecifiedDR CHERYL MEYERS
ILT37481Medicare UPIN
IL203488Medicare ID - Type UnspecifiedDR JEFFREY MEYERS