Provider Demographics
NPI:1255476099
Name:OPHTHALMOLOGY ASSOCIATES S C
Entity Type:Organization
Organization Name:OPHTHALMOLOGY ASSOCIATES S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-294-4660
Mailing Address - Street 1:6020 S PACKARD AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-3028
Mailing Address - Country:US
Mailing Address - Phone:414-294-4660
Mailing Address - Fax:
Practice Address - Street 1:2500 W LAYTON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5420
Practice Address - Country:US
Practice Address - Phone:414-281-0424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1849OtherRAILROAD MEDICARE
WI32758700Medicaid
0565030001Medicare NSC