Provider Demographics
NPI:1366475139
Name:PERRYSBURG EYE CENTER, INC.
Entity Type:Organization
Organization Name:PERRYSBURG EYE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-874-3125
Mailing Address - Street 1:28370 KENSINGTON LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-4163
Mailing Address - Country:US
Mailing Address - Phone:419-874-3125
Mailing Address - Fax:419-874-8606
Practice Address - Street 1:28370 KENSINGTON LN
Practice Address - Street 2:SUITE A
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-4163
Practice Address - Country:US
Practice Address - Phone:419-874-3125
Practice Address - Fax:419-874-8606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2415265Medicaid
OH=========00OtherWORKERS' COMPENSATION
OH=========00OtherWORKERS' COMPENSATION
OH2415265Medicaid