MEDICARE: TWO RIVERS EYE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist
2	156FX1800X	Optician
3	207W00000X	Ophthalmology Physician	44214-020	WI

General Provider Information

NPI Number	:	1114084324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWO RIVERS EYE CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 1900
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54221-1900
Country	:	US
Telephone Number	:	920-684-4429
Fax Number	:	920-684-6892

Provider Business Practice Location Address
First Line	:	1603 WASHINGTON ST
Second Line	:
City	:	TWO RIVERS
State	:	WI
Zip	:	54241-3021
Country	:	US
Telephone Number	:	920-793-2725
Fax Number	:

Authorized Official
Title or Position	:	OPHTHALMOLOGIST
Name	:	DR. STEVEN P GAINEY
Credential	:	M.D.
Telephone Number	:	920-684-4429

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	08/22/2007

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