=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134215338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SPRINGFIELD EYE SURGERY AND LASER CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 02/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 MORRIS AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07081-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-789-8999
-----------------------------------------------------
Fax | 908-789-8999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 MORRIS AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07081-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-789-8999
-----------------------------------------------------
Fax | 908-789-8999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | IVAN JACOBS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 908-789-8999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------