Provider Demographics
NPI:1861539694
Name:RETINA CENTER PC
Entity type:Organization
Organization Name:RETINA CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-569-2020
Mailing Address - Street 1:11710 OLD BALLAS RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7076
Mailing Address - Country:US
Mailing Address - Phone:314-569-2020
Mailing Address - Fax:314-569-1596
Practice Address - Street 1:11710 OLD BALLAS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7076
Practice Address - Country:US
Practice Address - Phone:314-569-2020
Practice Address - Fax:314-569-1596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004012770207W00000X
207WX0107X
MOR9531207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4498Medicare PIN
MO0000127078Medicare PIN