MEDICARE: FRY EYE SURGERY CENTER, LLC

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	261QM1300X	Multi-Specialty Clinic/Center
2	261QA1903X	Ambulatory Surgical Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528080876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRY EYE SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	411 CAMPUS DRIVE
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-6124
Country	:	US
Telephone Number	:	620-276-7699
Fax Number	:	620-276-7704

Provider Business Practice Location Address
First Line	:	411 CAMPUS DRIVE
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-6124
Country	:	US
Telephone Number	:	620-276-7699
Fax Number	:	620-276-7704

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL/OWNER
Name	:	DR. WILLIAM S CLIFFORD
Credential	:	M.D.
Telephone Number	:	620-275-7248

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	08/10/2015

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