Provider Demographics
NPI:1003141771
Name:PHOENIX RETINA CENTER, LLC
Entity type:Organization
Organization Name:PHOENIX RETINA CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:INGEBORG
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-278-8980
Mailing Address - Street 1:5410 N SCOTTSDALE RD
Mailing Address - Street 2:SUITE A400
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-5927
Mailing Address - Country:US
Mailing Address - Phone:480-278-8980
Mailing Address - Fax:
Practice Address - Street 1:5410 N SCOTTSDALE RD
Practice Address - Street 2:SUITE A400
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-5927
Practice Address - Country:US
Practice Address - Phone:480-278-8980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37088207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ69793OtherCHILDRENS MED SEC PLAN
AZ90546OtherFALLON COMM HEALTH PLAN
J28266OtherBLUE CROSS BLUE SHIELD
AZ2094514OtherFIRST HEALTH
AZA37828OtherMEDICARE B
AZ2098466Medicaid
AZ69793OtherHEALTHYSTART
784039OtherMVP HEALTH CARE
AZ042472266OtherHEALTHCARE VALUE MGMT
AZ042472266OtherTRICARE CAMPUS
042472266OtherONE HEALTH PLAN
AZAA15528OtherHARVARD PILGRIM HEALTHCARE
042472266OtherTHREE RIVERS
0801554OtherEVERCARE
2098466OtherMEDICAID WELFARE
AZ9317749OtherCIGNA HEALTH PLAN
042472266OtherPRIVATE HEALTHCARE SYSTEM
AZ7241458OtherAETNA US HEALTHCARE
AZ69793OtherCHILDRENS MED SEC PLAN