Basic Information
| Provider Information | |||||||||
| NPI: | 1174820856 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYECARE INDIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9795 CROSSPOINT BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172546480 | ||||||||
| FaxNumber: | 3172598609 | ||||||||
| Practice Location | |||||||||
| Address1: | 9795 CROSSPOINT BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172546480 | ||||||||
| FaxNumber: | 3172598609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2011 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | OSSIP | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3172546480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001899 | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 201095580 | 05 | IN | MEDICAID |