Provider Demographics
NPI:1083952113
Name:KU EYE SURGERY & LASER CENTER, LLC
Entity Type:Organization
Organization Name:KU EYE SURGERY & LASER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SUTPHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-588-6606
Mailing Address - Street 1:7400 STATE LINE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-3444
Mailing Address - Country:US
Mailing Address - Phone:913-588-6626
Mailing Address - Fax:913-588-0888
Practice Address - Street 1:7400 STATE LINE RD
Practice Address - Street 2:SUITE 212
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-3444
Practice Address - Country:US
Practice Address - Phone:913-588-2020
Practice Address - Fax:913-574-1087
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KANSAS UNIVERSITY OPHTHALMIC FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-24
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4652236261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201099022AMedicaid
KA3250OtherMEDICARE PTAN
KA3250Medicare PIN