Provider Demographics
NPI:1790917102
Name:SPECIALEYES PROFESSIONAL EYE CARE SERVICES, PLLC
Entity Type:Organization
Organization Name:SPECIALEYES PROFESSIONAL EYE CARE SERVICES, PLLC
Other - Org Name:PEAK VIEW EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BALDWIN
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-877-2422
Mailing Address - Street 1:27 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERGENNES
Mailing Address - State:VT
Mailing Address - Zip Code:05491-1113
Mailing Address - Country:US
Mailing Address - Phone:802-877-2422
Mailing Address - Fax:802-877-1124
Practice Address - Street 1:27 MAIN ST
Practice Address - Street 2:
Practice Address - City:VERGENNES
Practice Address - State:VT
Practice Address - Zip Code:05491-1113
Practice Address - Country:US
Practice Address - Phone:802-877-2422
Practice Address - Fax:802-877-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0000013132OtherMEDICARE PTAN
VT1790917102OtherBC BS OF VERMONT
VT200072249OtherMVP