Provider Demographics
NPI:1508838954
Name:DAVENPORT EYE GROUP PC
Entity Type:Organization
Organization Name:DAVENPORT EYE GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIV
Authorized Official - Middle Name:BRIT
Authorized Official - Last Name:SAETRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-322-0923
Mailing Address - Street 1:1230 E RUSHOLME ST
Mailing Address - Street 2:STE 203
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2400
Mailing Address - Country:US
Mailing Address - Phone:563-322-0923
Mailing Address - Fax:563-322-7403
Practice Address - Street 1:1230 E RUSHOLME ST
Practice Address - Street 2:STE 203
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2400
Practice Address - Country:US
Practice Address - Phone:563-322-0923
Practice Address - Fax:563-322-7403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0286468Medicaid
CE7597OtherMEDICARE RR
IA71964Medicare PIN
IA0535960001Medicare NSC
IL0535960001Medicare NSC
71964Medicare ID - Type Unspecified