Provider Demographics
NPI:1902076714
Name:PHYSICIAN'S EYE CENTER, PSC
Entity Type:Organization
Organization Name:PHYSICIAN'S EYE CENTER, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:W DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-278-9373
Mailing Address - Street 1:1701 NICHOLASVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1403
Mailing Address - Country:US
Mailing Address - Phone:859-278-9373
Mailing Address - Fax:
Practice Address - Street 1:1701 NICHOLASVILLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1403
Practice Address - Country:US
Practice Address - Phone:859-278-9373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2442Medicare PIN