Provider Demographics
NPI:1861894115
Name:PEE DEE EYE ASSOCIATES, PA
Entity type:Organization
Organization Name:PEE DEE EYE ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-332-7171
Mailing Address - Street 1:PO BOX 1956
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1956
Mailing Address - Country:US
Mailing Address - Phone:803-775-1772
Mailing Address - Fax:803-775-4729
Practice Address - Street 1:528 BROAD ST
Practice Address - Street 2:STE 101
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-3368
Practice Address - Country:US
Practice Address - Phone:803-775-1772
Practice Address - Fax:803-775-4729
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEE DEE EYE ASSOCIATES, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1422152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC459665Medicaid
SCD04546Medicaid
SCD13340Medicaid
SC459665Medicaid
SCT25034Medicare UPIN
SCD13340Medicaid
SCAA0623Medicare PIN
SCT23884Medicare UPIN
SCT250347463Medicare PIN
SCAA14847463Medicare PIN
SCT23760Medicare UPIN