Basic Information
| Provider Information | |||||||||
| NPI: | 1083098016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST EYE SURGERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 CHANCELLOR DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593442079 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Practice Location | |||||||||
| Address1: | 4452 EASTGATE BLVD | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452451584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137525700 | ||||||||
| FaxNumber: | 5137525716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | BARBERY | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8593442062 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 261QS0132X | 0087AS | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0163517 | 05 | OH | MEDICAID | 7100401680 | 05 | KY | MEDICAID | 490002965 | 01 | RR MEDICARE | OTHER |