Provider Demographics
NPI:1477526143
Name:FT MYERS FL OPHTHALMOLOGY ASC LLC
Entity Type:Organization
Organization Name:FT MYERS FL OPHTHALMOLOGY ASC LLC
Other - Org Name:UNIVERSITY EYE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:13051 UNIVERSITY DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5751
Mailing Address - Country:US
Mailing Address - Phone:239-590-6111
Mailing Address - Fax:239-590-0781
Practice Address - Street 1:13051 UNIVERSITY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5751
Practice Address - Country:US
Practice Address - Phone:239-590-6111
Practice Address - Fax:239-590-0781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1075261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075359900Medicaid
FL075359900Medicaid
FL490005537Medicare PIN
FLF1308Medicare PIN
FL=========OtherTRICARE