Provider Demographics
NPI:1942609094
Name:MEDICAL CITY EYE CENTER PA
Entity Type:Organization
Organization Name:MEDICAL CITY EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-984-3200
Mailing Address - Street 1:214 E MARKS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3819
Mailing Address - Country:US
Mailing Address - Phone:407-841-6220
Mailing Address - Fax:407-423-2285
Practice Address - Street 1:214 E MARKS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3819
Practice Address - Country:US
Practice Address - Phone:407-841-6220
Practice Address - Fax:407-423-2285
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREVARD EYE CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1134152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19928ZMedicare PIN
FL0455110001Medicare NSC
FLGK930ZMedicare PIN