Provider Demographics
NPI:1841480399
Name:PIEDMONT RETINA ASSOC., P.A.
Entity type:Organization
Organization Name:PIEDMONT RETINA ASSOC., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCLANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-232-1636
Mailing Address - Street 1:317 SAINT FRANCIS DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3965
Mailing Address - Country:US
Mailing Address - Phone:864-232-1636
Mailing Address - Fax:864-232-8695
Practice Address - Street 1:317 SAINT FRANCIS DR
Practice Address - Street 2:SUITE 330
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3965
Practice Address - Country:US
Practice Address - Phone:864-232-1636
Practice Address - Fax:864-232-8695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10329207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0198Medicaid
SC3751Medicare UPIN