Basic Information
| Provider Information | |||||||||
| NPI: | 1528080876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRY EYE SURGERY CENTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 411 CAMPUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678466124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202767699 | ||||||||
| FaxNumber: | 6202767704 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 CAMPUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678466124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202767699 | ||||||||
| FaxNumber: | 6202767704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLIFFORD | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6202757248 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 100750170A | 05 | OK | MEDICAID | 94510021 | 05 | CO | MEDICAID | 100305010A | 05 | KS | MEDICAID |