Provider Demographics
NPI:1285639666
Name:RETINA ASSOCIATES, PSC
Entity Type:Organization
Organization Name:RETINA ASSOCIATES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRUSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, FACHE, COE
Authorized Official - Phone:502-589-1500
Mailing Address - Street 1:1536 STORY AVE
Mailing Address - Street 2:THE EYE CARE INSTITUTE BUILDING
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-1738
Mailing Address - Country:US
Mailing Address - Phone:502-589-1500
Mailing Address - Fax:502-589-1556
Practice Address - Street 1:1536 STORY AVE
Practice Address - Street 2:THE EYE CARE INSTITUTE BUILDING
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1738
Practice Address - Country:US
Practice Address - Phone:502-589-1500
Practice Address - Fax:502-589-1556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1136DT152W00000X
KY1614DT152W00000X
KY1613DT152W00000X
KY31573207W00000X
KY28804207W00000X
KY28590207W00000X
IN01043769207W00000X
IN01043733207W00000X
IN01040010207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY779033591OtherGROUP OD MEDICAID NUMBER
IN100221560AMedicaid
KY1121048OtherGROUP PASSPORT NUMBER
KY65917502Medicaid
KYCF7698OtherGROUP RR MEDICARE NUMBER
IN730810Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
0842700001Medicare NSC
KY65917502Medicaid