Provider Demographics
NPI:1407865769
Name:SOUTH GROVE EYE CARE, PC
Entity Type:Organization
Organization Name:SOUTH GROVE EYE CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-535-3935
Mailing Address - Street 1:373 MERIDIAN PARKE LN STE E
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9419
Mailing Address - Country:US
Mailing Address - Phone:317-535-3905
Mailing Address - Fax:317-535-3905
Practice Address - Street 1:373 MERIDIAN PARKE LN STE E
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9419
Practice Address - Country:US
Practice Address - Phone:317-535-3905
Practice Address - Fax:317-886-4945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN56000358A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5767090001Medicare NSC
IN247470Medicare PIN