Provider Demographics
NPI:1427002864
Name:THE EYE CLINIC PA
Entity Type:Organization
Organization Name:THE EYE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:228-864-2633
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-0148
Mailing Address - Country:US
Mailing Address - Phone:228-864-2633
Mailing Address - Fax:228-865-0339
Practice Address - Street 1:1900 23RD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2965
Practice Address - Country:US
Practice Address - Phone:228-864-2633
Practice Address - Fax:228-865-0339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013545Medicaid
MSC00757Medicare ID - Type UnspecifiedMEDICARE GROUP ID
MS0300930001Medicare NSC