Provider Demographics
NPI:1841499670
Name:MASSACHUSETTS SOUTH EASTERN EYE CENTER, INC.
Entity type:Organization
Organization Name:MASSACHUSETTS SOUTH EASTERN EYE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:508-295-3193
Mailing Address - Street 1:40 CHURCH ST AVENUE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-2093
Mailing Address - Country:US
Mailing Address - Phone:508-295-3193
Mailing Address - Fax:508-295-4635
Practice Address - Street 1:40 CHURCH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-2093
Practice Address - Country:US
Practice Address - Phone:508-295-3193
Practice Address - Fax:508-295-4635
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASSACHUSETTS SOUTH EASTERN EYE CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-12
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53631174400000X
MA156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110071159AMedicaid
MA9758178Medicaid
MA715421OtherTUFTS HEALTHCARE
MA110071159AMedicaid