Provider Demographics
NPI:1780852608
Name:GARDNER EYE ASSOCIATES INC
Entity Type:Organization
Organization Name:GARDNER EYE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FOTIOS
Authorized Official - Middle Name:N
Authorized Official - Last Name:GANIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-632-7626
Mailing Address - Street 1:250 GREEN ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440
Mailing Address - Country:US
Mailing Address - Phone:978-632-7626
Mailing Address - Fax:978-632-0227
Practice Address - Street 1:250 GREEN ST
Practice Address - Street 2:SUITE 106
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440
Practice Address - Country:US
Practice Address - Phone:978-632-7626
Practice Address - Fax:978-632-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36819207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2019698Medicaid
M12402Medicare PIN
MA2019698Medicaid