Provider Demographics
NPI:1205023363
Name:EYE ASSOCIATES OF SOUTHERN INDIANA PC
Entity Type:Organization
Organization Name:EYE ASSOCIATES OF SOUTHERN INDIANA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-284-0660
Mailing Address - Street 1:1350 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-9190
Mailing Address - Country:US
Mailing Address - Phone:812-896-1717
Mailing Address - Fax:
Practice Address - Street 1:1350 S JACKSON STREET
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-7218
Practice Address - Country:US
Practice Address - Phone:812-896-1717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1155450004Medicare NSC