Provider Demographics
NPI:1619026671
Name:OPHTHALMIC SURGEONS OF GR BPT PC
Entity Type:Organization
Organization Name:OPHTHALMIC SURGEONS OF GR BPT PC
Other - Org Name:OPTICAL ILLUSIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOBIERAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-371-0141
Mailing Address - Street 1:2371 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3229
Mailing Address - Country:US
Mailing Address - Phone:203-371-0141
Mailing Address - Fax:203-371-6585
Practice Address - Street 1:2371 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3229
Practice Address - Country:US
Practice Address - Phone:203-371-0141
Practice Address - Fax:203-371-6585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004001665Medicaid
CT004001665Medicaid
CT0788320001Medicare NSC