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General NPI Number Information
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NPI Number | 1205204377
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE CENTER FOR SIGHT
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Dates
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Enumeration Date | 09/08/2015
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Last Update Date | 03/31/2016
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Provider Practice Location Address
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Address Line | 701 E COUNTY LINE ROAD SUITE 202
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City | GREENWOOD
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State | IN
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Zip | 46143-1071
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Country | US
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Telephone | 317-215-2833
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Fax | 317-215-2838
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Provider Business Mailing Address
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Address Line | 701 E COUNTY LINE ROAD SUITE 202
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City | GREENWOOD
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State | IN
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Zip | 46143-1071
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Country | US
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Telephone | 317-215-2833
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Fax | 317-215-2838
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTOPHER BAUER PESAVENTO
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Credential | MD
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Telephone | 317-215-2833
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State | IN
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