Provider Demographics
NPI:1821108192
Name:SOUTHERN VISION CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHERN VISION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:GILILAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-491-3435
Mailing Address - Street 1:105 GREAT SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-4001
Mailing Address - Country:US
Mailing Address - Phone:614-491-3435
Mailing Address - Fax:614-491-1699
Practice Address - Street 1:105 GREAT SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4001
Practice Address - Country:US
Practice Address - Phone:614-491-3435
Practice Address - Fax:614-491-1699
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN VISION CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-30
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3605152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH281566897004OtherMEDICAL MUTUAL
OH000000120727OtherANTHEM
OH1184130001OtherDMERC
OH2200190OtherUNITED HEALTHCARE
OH2200190OtherUNITED HEALTHCARE