=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366429102
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPHTHALMOLOGY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2005
-----------------------------------------------------
Last Update Date | 07/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 E MANNING ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02906-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-272-2020
-----------------------------------------------------
Fax | 401-421-5979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 E MANNING ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02906-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-272-2020
-----------------------------------------------------
Fax | 401-421-5979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTS MANAGER
-----------------------------------------------------
Name | GAIL P DUELL
-----------------------------------------------------
Credential | CPC, CEMC
-----------------------------------------------------
Telephone | 401-272-2010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODTA00377
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | MD05032
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------