Provider Demographics
NPI:1649223744
Name:SOUTH COUNTY PHYSICIANS AND SURGEONS INC - OPTICAL SHOPE
Entity Type:Organization
Organization Name:SOUTH COUNTY PHYSICIANS AND SURGEONS INC - OPTICAL SHOPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:COGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-294-4506
Mailing Address - Street 1:65 BOSTON NECK ROAD
Mailing Address - Street 2:SOUTH COUNTY EYE PHYSICIANS AND SURGEONS INC
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-5704
Mailing Address - Country:US
Mailing Address - Phone:401-295-0723
Mailing Address - Fax:401-295-8870
Practice Address - Street 1:65 BOSTON NECK ROAD
Practice Address - Street 2:SOUTH COUNTY EYE PHYSICIANS AND SURGEONS INC
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5704
Practice Address - Country:US
Practice Address - Phone:401-295-0723
Practice Address - Fax:401-295-8870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9000324Medicaid
RI0963OtherNEIGHBORHOOD HEALTH PLAN
RI9000324Medicaid
RI0449310001Medicare ID - Type Unspecified
RI9000324Medicaid