Provider Demographics
NPI:1790939254
Name:CLEMSON OPHTHALMOLOGY
Entity Type:Organization
Organization Name:CLEMSON OPHTHALMOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FISK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-654-6706
Mailing Address - Street 1:P.O. BOX 1666
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633
Mailing Address - Country:US
Mailing Address - Phone:864-654-6706
Mailing Address - Fax:864-654-3275
Practice Address - Street 1:931 TIGER BLVD
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1419
Practice Address - Country:US
Practice Address - Phone:864-654-6706
Practice Address - Fax:864-654-3275
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEMOSON OPHTHALMOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1054152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9729Medicaid