Provider Demographics
NPI:1952315939
Name:EYE PHYSICIANS OF SPRINGFIELD, INC
Entity Type:Organization
Organization Name:EYE PHYSICIANS OF SPRINGFIELD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-399-8287
Mailing Address - Street 1:2254 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2737
Mailing Address - Country:US
Mailing Address - Phone:937-399-8287
Mailing Address - Fax:937-399-1670
Practice Address - Street 1:2254 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2737
Practice Address - Country:US
Practice Address - Phone:937-399-8287
Practice Address - Fax:937-399-1670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0242426Medicaid
OH0242426Medicaid