1326210451 NPI number — CALVERT OPTHALMOLOGY PSC

Table of content: (NPI 1326210451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326210451 NPI number — CALVERT OPTHALMOLOGY PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALVERT OPTHALMOLOGY PSC
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:
CALVERT OPHTHALMOLOGY CENTER
Provider Other Organization Name Type Code:
3
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:
1326210451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 KEETON DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPKINSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42240-8756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-886-2050
Provider Business Mailing Address Fax Number:
270-886-2007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 CLEAR SKY COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-647-4900
Provider Business Practice Location Address Fax Number:
931-647-1333
Provider Enumeration Date:
03/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CALVERT
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
MILTON
Authorized Official Title or Position:
PRESIDENT/MD
Authorized Official Telephone Number:
270-886-2050

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD0000035976 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3704121 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4061554 . This is a "BLUECROSS GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 01035351 . This is a "TN AMERIGROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 180045298 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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