Provider Demographics
NPI:1649242967
Name:THOMAS K. MARSH, ODSC
Entity Type:Organization
Organization Name:THOMAS K. MARSH, ODSC
Other - Org Name:PRIMARY EYECARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-567-3214
Mailing Address - Street 1:1280 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4445
Mailing Address - Country:US
Mailing Address - Phone:262-567-3214
Mailing Address - Fax:262-567-2449
Practice Address - Street 1:1280 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4445
Practice Address - Country:US
Practice Address - Phone:262-567-3214
Practice Address - Fax:262-567-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1507-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38564400Medicaid
WIT62683Medicare UPIN
WI38564400Medicaid
WI0414490001Medicare NSC