1750495263 NPI number — COMPREHENSIVE EYE CARE OF INDIANA PC

Table of content: (NPI 1750495263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750495263 NPI number — COMPREHENSIVE EYE CARE OF INDIANA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE EYE CARE OF INDIANA PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750495263
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6418 LANDBOROUGH SOUTH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46220-4357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-845-1305
Provider Business Mailing Address Fax Number:
317-842-3621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7301 N SHADELAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46250-2085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-845-1305
Provider Business Practice Location Address Fax Number:
317-842-3621
Provider Enumeration Date:
08/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCCORD
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
ELLIOTT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-845-1305

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  50003808A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000104148 . This is a "ANTHEM BLUE NETWORK" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 317426300 . This is a "TRICARE CHAMPUS" identifier . This identifiers is of the category "OTHER".