Provider Demographics
NPI:1114084324
Name:TWO RIVERS EYE CLINIC
Entity Type:Organization
Organization Name:TWO RIVERS EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GAINEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-684-4429
Mailing Address - Street 1:PO BOX 1900
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-1900
Mailing Address - Country:US
Mailing Address - Phone:920-684-4429
Mailing Address - Fax:920-684-6892
Practice Address - Street 1:1603 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3021
Practice Address - Country:US
Practice Address - Phone:920-793-2725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 156FX1800X
WI44214-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0376640002Medicare ID - Type UnspecifiedADMINASTAR FEDERAL