1962533851 NPI number — EYE ASSOCIATES OF SOUTHERN INDIANA PC

Table of content: (NPI 1962533851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962533851 NPI number — EYE ASSOCIATES OF SOUTHERN INDIANA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE ASSOCIATES OF SOUTHERN 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:
6
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:
1962533851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
302 W 14TH ST STE 100A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSONVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47130-3751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-280-2162
Provider Business Mailing Address Fax Number:
812-284-3822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
643 COMANCHE TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40601-1753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-227-4508
Provider Business Practice Location Address Fax Number:
502-226-3315
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PUGH
Authorized Official First Name:
KRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER MD
Authorized Official Telephone Number:
812-284-0660

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1520DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00021169 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77000420 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000280798 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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