Provider Demographics
NPI:1477633071
Name:SURGERY CENTER OF EYE SPECIALISTS OF INDIANA, PC
Entity Type:Organization
Organization Name:SURGERY CENTER OF EYE SPECIALISTS OF INDIANA, PC
Other - Org Name:SURGERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-925-2200
Mailing Address - Street 1:1901 NORTH MERIDIAN STREET
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-925-2200
Mailing Address - Fax:317-921-6614
Practice Address - Street 1:1901 NORTH MERIDIAN STREET
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-925-2200
Practice Address - Fax:317-921-6614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003654A261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000098114OtherBLUE CROSS BLUE SHIELD
IN100103070AMedicaid
000000098114OtherBLUE CROSS BLUE SHIELD