Provider Demographics
NPI:1881817732
Name:GREENVILLE EYE CLINIC P.A.
Entity Type:Organization
Organization Name:GREENVILLE EYE CLINIC P.A.
Other - Org Name:THE EYE CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-332-0163
Mailing Address - Street 1:239 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-4234
Mailing Address - Country:US
Mailing Address - Phone:662-332-0163
Mailing Address - Fax:662-378-3394
Practice Address - Street 1:239 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4234
Practice Address - Country:US
Practice Address - Phone:662-332-0163
Practice Address - Fax:662-378-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880088Medicaid
1160110001OtherPALMETTO GBA
=========OtherUNITED HEALTHCARE
=========OtherVISION SERVICE PLAN
=========OtherBLUE CROSS BLUE SHIELD MS
1160110001OtherPALMETTO GBA
=========OtherVISION CARE, INC.
MS00880088Medicaid
=========OtherSECURE HORIZONS DIRECT
=========OtherEYEMED VISION CARE
MS=========OtherAHS STATE NETWORK
MS00880088Medicaid