Basic Information
| Provider Information | |||||||||
| NPI: | 1881728590 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYSTEM OPTICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 518 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | TALLMADGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442782117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306309699 | ||||||||
| FaxNumber: | 3306337165 | ||||||||
| Practice Location | |||||||||
| Address1: | 518 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | TALLMADGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442782117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306309699 | ||||||||
| FaxNumber: | 3306337165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | BEYER | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3306309699 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 507 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 490004292 | 01 | OH | RAILROAD MEDICARE | OTHER | 2725108 | 05 | OH | MEDICAID | 000000233057 | 01 | ANTHEM | OTHER | 9002432 | 01 | SUMMACARE | OTHER | 341571960 | 01 | AETNA | OTHER | 100770 | 01 | KAISER PERMANENTE | OTHER | 406252 | 01 | UNITED HEALTHCARE | OTHER |