Provider Demographics
NPI:1245228204
Name:EYE PHYSICIANS OF ELIZABETHTOWN PSC
Entity Type:Organization
Organization Name:EYE PHYSICIANS OF ELIZABETHTOWN PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-765-6066
Mailing Address - Street 1:1109 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2749
Mailing Address - Country:US
Mailing Address - Phone:270-765-6066
Mailing Address - Fax:270-737-2354
Practice Address - Street 1:1109 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2749
Practice Address - Country:US
Practice Address - Phone:270-765-6066
Practice Address - Fax:270-737-2354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65924607Medicaid
KY65924607Medicaid