Provider Demographics
NPI:1417131558
Name:MIDWEST RETINA, INC
Entity Type:Organization
Organization Name:MIDWEST RETINA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:L
Authorized Official - Last Name:TURK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-233-9500
Mailing Address - Street 1:500 E MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5369
Mailing Address - Country:US
Mailing Address - Phone:614-233-9500
Mailing Address - Fax:614-233-9501
Practice Address - Street 1:500 E MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5369
Practice Address - Country:US
Practice Address - Phone:614-233-9500
Practice Address - Fax:614-233-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH35067637207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0164405Medicaid
OH274805710011OtherMEDICAL MUTUAL
OH5730181OtherAETNA
OH5730181OtherAETNA