=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124012737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RETINA-VITREOUS SURGEONS OF CENTRAL NEW YORK, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2005
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 GREENFIELD PKWY
-----------------------------------------------------
City | LIVERPOOL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13088-6655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-445-8166
-----------------------------------------------------
Fax | 315-445-2697
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 GREENFIELD PKWY
-----------------------------------------------------
City | LIVERPOOL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13088-6655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-445-8166
-----------------------------------------------------
Fax | 315-445-2697
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS SERVICES COORDINATOR
-----------------------------------------------------
Name | MRS. ANNE SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-445-8166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------