=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518139385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRINGFIELD EYE GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 01/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1674 NORTH LIMESTONE ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-399-4101
-----------------------------------------------------
Fax | 937-399-2346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1674 N LIMESTONE ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45503-2652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-399-4101
-----------------------------------------------------
Fax | 937-399-2346
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SARAH ELIZABETH ROGERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-399-4101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 4831
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number | 4831
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WX0102X
-----------------------------------------------------
Taxonomy Name | Occupational Vision Optometrist
-----------------------------------------------------
License Number | 4831
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4831
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------