Provider Demographics
NPI:1295729382
Name:EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP INC
Entity type:Organization
Organization Name:EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMTHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-823-0229
Mailing Address - Street 1:6880 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4270
Mailing Address - Country:US
Mailing Address - Phone:707-823-7628
Mailing Address - Fax:707-823-1521
Practice Address - Street 1:6880 PALM AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4270
Practice Address - Country:US
Practice Address - Phone:707-823-7628
Practice Address - Fax:707-823-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ16441ZOtherBLUE SHIELD
CAGR0083382Medicaid
CA05D1077728OtherCLIA
CAGR0083381Medicaid
CAGR0083383Medicaid
CACI4202OtherMEDICARE RET RAILROAD
CA1247100001OtherDMERC
CAZZZ88771ZOtherBLUE SHIELD
CAGR0083380Medicaid
CA1247100001OtherDMERC
CAA47659Medicare UPIN
CAG389840Medicare UPIN
CAZZZ15282ZMedicare ID - Type UnspecifiedMEDICARE/SEBASTOPOL
CAGR0083382Medicaid
CAGR0083381Medicaid