Provider Demographics
NPI:1457300683
Name:EYE SPECIALIST INC
Entity Type:Organization
Organization Name:EYE SPECIALIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:800-948-3937
Mailing Address - Street 1:50 N PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-1757
Mailing Address - Country:US
Mailing Address - Phone:866-587-8790
Mailing Address - Fax:740-774-4061
Practice Address - Street 1:505 WEST EMMITT AVENUE
Practice Address - Street 2:SUITE 4
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1084
Practice Address - Country:US
Practice Address - Phone:740-941-3937
Practice Address - Fax:740-941-3786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2368941Medicaid
OH2368941Medicaid