Provider Demographics
NPI:1316398514
Name:CIRCLE CITY NEURO-OPHTHALMOLOGY, LLC
Entity Type:Organization
Organization Name:CIRCLE CITY NEURO-OPHTHALMOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-808-3433
Mailing Address - Street 1:10300 N ILLINOIS ST STE 1000
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1167
Mailing Address - Country:US
Mailing Address - Phone:317-805-2240
Mailing Address - Fax:317-527-4708
Practice Address - Street 1:10300 N ILLINOIS ST STE 1000
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46290-1167
Practice Address - Country:US
Practice Address - Phone:317-805-2240
Practice Address - Fax:317-527-4708
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAI VISION AND SURGERY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-29
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074332A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ3066Medicare PIN