Provider Demographics
NPI:1154497964
Name:PANKRATZ EYE INSTITUTE, LLC
Entity Type:Organization
Organization Name:PANKRATZ EYE INSTITUTE, LLC
Other - Org Name:COLUMBUS EYE SUGERY CENTER, LLC, DBA PANKRATZ EYE INSTITUTE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PANKRATZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-373-7777
Mailing Address - Street 1:3135 MIDDLE ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-4472
Mailing Address - Country:US
Mailing Address - Phone:812-373-7777
Mailing Address - Fax:812-373-0772
Practice Address - Street 1:3135 MIDDLE ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4472
Practice Address - Country:US
Practice Address - Phone:812-373-7777
Practice Address - Fax:812-373-0772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-002663-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200318350AMedicaid
IN000000181745OtherANTHEM PIN
IN000000181745OtherANTHEM PIN