Basic Information
| Provider Information | |||||||||
| NPI: | 1285967661 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE SPECIALISTS OF EAST CENTRAL INDIANA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KOKOMO EYE SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2302 S DIXON RD | ||||||||
| Address2: | #100 | ||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469026424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654533937 | ||||||||
| FaxNumber: | 7654558750 | ||||||||
| Practice Location | |||||||||
| Address1: | 2302 S DIXON RD | ||||||||
| Address2: | #100 | ||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469026424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654533937 | ||||||||
| FaxNumber: | 7654558750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2009 | ||||||||
| LastUpdateDate: | 10/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | SCANAMEO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7654533997 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.