Provider Demographics
NPI:1922138353
Name:PEDIATRIC EYE CARE OF THE HEARTLAND, LLC
Entity Type:Organization
Organization Name:PEDIATRIC EYE CARE OF THE HEARTLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYBETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:KAPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-334-7427
Mailing Address - Street 1:3065 WILLIAM ST
Mailing Address - Street 2:STE 207
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6393
Mailing Address - Country:US
Mailing Address - Phone:573-334-7427
Mailing Address - Fax:573-334-5970
Practice Address - Street 1:3065 WILLIAM ST
Practice Address - Street 2:STE 207
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6393
Practice Address - Country:US
Practice Address - Phone:573-334-7427
Practice Address - Fax:573-334-5970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2K43174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE84670Medicare UPIN