Provider Demographics
NPI:1346233905
Name:AMBULATORY SURGERY CENTER AT INDIANA EYE CLINIC LLC
Entity Type:Organization
Organization Name:AMBULATORY SURGERY CENTER AT INDIANA EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUSZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-881-3937
Mailing Address - Street 1:30 N EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-8895
Mailing Address - Country:US
Mailing Address - Phone:317-881-3937
Mailing Address - Fax:317-887-4009
Practice Address - Street 1:30 N EMERSON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8895
Practice Address - Country:US
Practice Address - Phone:317-881-3937
Practice Address - Fax:317-887-4012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-005394-2261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000217839OtherBCBS
IN490005398OtherRAILROAD MEDICARE
IN100274240AMedicaid
IN=========OtherAETNA
IN100274240AMedicaid