Basic Information
| Provider Information | |||||||||
| NPI: | 1376513440 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA EYE CLINIC AMBULATORY SURGERY CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 BOSTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078347776 | ||||||||
| FaxNumber: | 4078340973 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 BOSTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078347776 | ||||||||
| FaxNumber: | 4078340973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | PAPPAS | ||||||||
| AuthorizedOfficialFirstName: | HARRY | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4078347776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 945 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 062926000 | 05 | FL | MEDICAID | 033553300 | 05 | FL | MEDICAID |