Provider Demographics
NPI:1407858673
Name:THE RETINA INSTITUTE LLC
Entity Type:Organization
Organization Name:THE RETINA INSTITUTE LLC
Other - Org Name:BARNES RETINA INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:M GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-367-1181
Mailing Address - Street 1:1600 S BRENTWOOD BLVD
Mailing Address - Street 2:STE 800
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1317
Mailing Address - Country:US
Mailing Address - Phone:314-367-1181
Mailing Address - Fax:314-968-5117
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:STE 12B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-367-1181
Practice Address - Fax:314-968-5117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MON/A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO541OtherBCBS
IL04121950OtherBCBS
MO502111305Medicaid
MO000012214Medicare PIN
IL203328Medicare PIN
IL368370Medicare PIN