Provider Demographics
NPI:1578881009
Name:EYE LASER AND SURGERY CENTER LLC
Entity Type:Organization
Organization Name:EYE LASER AND SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:STAHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-427-2020
Mailing Address - Street 1:4235 INDIAN RIPPLE RD
Mailing Address - Street 2:STE 110
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3265
Mailing Address - Country:US
Mailing Address - Phone:937-427-7800
Mailing Address - Fax:937-427-7803
Practice Address - Street 1:4235 INDIAN RIPPLE RD
Practice Address - Street 2:STE 110
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3265
Practice Address - Country:US
Practice Address - Phone:937-427-7800
Practice Address - Fax:937-427-7803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-07
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0991AS261QA1903X, 261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0055714Medicaid
OHH017510Medicare PIN
OH0055714Medicaid