Basic Information
| Provider Information | |||||||||
| NPI: | 1497934764 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRUCE P MATHIE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1403 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446412310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308754320 | ||||||||
| FaxNumber: | 3308754305 | ||||||||
| Practice Location | |||||||||
| Address1: | 1403 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446412310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308754320 | ||||||||
| FaxNumber: | 3308754305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 12/22/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATHIE | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3308754320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4803 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 297661819005 | 01 | OH | MEDICAL MUTUAL | OTHER | 2039127 | 05 | OH | MEDICAID | 2708610 | 01 | OH | AETNA | OTHER | 000000223574 | 01 | OH | ANTHEM | OTHER | 410048659 | 01 | OH | RAILRODE MEDICARE | OTHER |