Provider Demographics
NPI:1871643585
Name:HOLLINGSHEAD EYE CENTER, PC
Entity Type:Organization
Organization Name:HOLLINGSHEAD EYE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:PENNOW
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:208-336-8700
Mailing Address - Street 1:360 E MALLARD DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6644
Mailing Address - Country:US
Mailing Address - Phone:208-336-8700
Mailing Address - Fax:208-426-0902
Practice Address - Street 1:360 E MALLARD DR
Practice Address - Street 2:SUITE 110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6644
Practice Address - Country:US
Practice Address - Phone:208-336-8700
Practice Address - Fax:208-426-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100159152W00000X
IDM6436207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805858400Medicaid
ID805858500Medicaid
IDE78693Medicare UPIN
ID180038517Medicare PIN
ID805858500Medicaid
ID1377164Medicare ID - Type UnspecifiedMARK E HOLLINGSHEAD, M.D.
ID805858400Medicaid