Provider Demographics
NPI:1548605124
Name:EYECARE INDIANA
Entity Type:Organization
Organization Name:EYECARE INDIANA
Other - Org Name:BLOOMINGTON EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:L
Authorized Official - Last Name:OSSIP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-254-6480
Mailing Address - Street 1:9795 CROSSPOINT BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3354
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:2600 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-5227
Practice Address - Country:US
Practice Address - Phone:812-336-5432
Practice Address - Fax:812-332-5084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001887152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201095580Medicaid
IN201095580Medicaid