Provider Demographics
NPI:1003806068
Name:EMPIRE EYE DOCTORS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:EMPIRE EYE DOCTORS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-575-3800
Mailing Address - Street 1:720 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4421
Mailing Address - Country:US
Mailing Address - Phone:707-575-3800
Mailing Address - Fax:707-528-4967
Practice Address - Street 1:720 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4421
Practice Address - Country:US
Practice Address - Phone:707-575-3800
Practice Address - Fax:707-528-4967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8739T152W00000X
CAT10471152W00000X
CA8817T152WL0500X
CAG32243207W00000X
CAG57122207W00000X
CAG32019207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5395OtherRAILROAD MEDICARE
CAGR0016130Medicaid
CAZZZ92901ZMedicare PIN
CACP5395OtherRAILROAD MEDICARE