Provider Demographics
NPI:1205204377
Name:SOUTHSIDE CENTER FOR SIGHT
Entity Type:Organization
Organization Name:SOUTHSIDE CENTER FOR SIGHT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:BAUER
Authorized Official - Last Name:PESAVENTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-215-2833
Mailing Address - Street 1:701 E COUNTY LINE ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1071
Mailing Address - Country:US
Mailing Address - Phone:317-215-2833
Mailing Address - Fax:317-215-2838
Practice Address - Street 1:701 E COUNTY LINE ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1071
Practice Address - Country:US
Practice Address - Phone:317-215-2833
Practice Address - Fax:317-215-2838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INI65406Medicare UPIN
ININ2731Medicare PIN