Provider Demographics
NPI:1730180274
Name:ASSOCIATED EYE PHYSICIANS & SURGEONS INC
Entity type:Organization
Organization Name:ASSOCIATED EYE PHYSICIANS & SURGEONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BORODIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-770-0011
Mailing Address - Street 1:340 MAIN ST
Mailing Address - Street 2:SUITE 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-754-3566
Mailing Address - Fax:508-798-8012
Practice Address - Street 1:1261 FURNACE BROOK PKWY
Practice Address - Street 2:SUITE 15
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4721
Practice Address - Country:US
Practice Address - Phone:617-770-0011
Practice Address - Fax:617-770-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9770224Medicaid
MA9770224Medicaid