MEDICARE: PENINSULA 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	261QA1903X	Ambulatory Surgical Clinic/Center
2	261QS0132X	Ophthalmologic Surgery Clinic/Center	550000072	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AS1737	OTHER		BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770652216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENINSULA EYE SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	1128 W EL CAMINO REAL
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-2518
Country	:	US
Telephone Number	:	650-964-3200
Fax Number	:	650-964-3206

Provider Business Practice Location Address
First Line	:	1128 W EL CAMINO REAL
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-2518
Country	:	US
Telephone Number	:	650-964-3200
Fax Number	:	650-964-3206

Authorized Official
Title or Position	:	VP
Name	:	JEFFREY M FIELDS
Credential	:
Telephone Number	:	205-545-2572

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/21/2014

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