=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629280813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREATER LAFAYETTE RETINA CENTER, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 06/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1013 N 13TH ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-428-8888
-----------------------------------------------------
Fax | 765-428-8889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1013 N 13TH ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-428-8888
-----------------------------------------------------
Fax | 765-428-8889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING DEPARTMENT
-----------------------------------------------------
Name | PHYLLIS M. WATKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 765-428-8888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 01057576A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------