=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669663233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED EYE CARE OF THE UPSTATE, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2007
-----------------------------------------------------
Last Update Date | 08/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 ENTERPRISE BLVD SUITE 208
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-6301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-254-6070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 ENTERPRISE BLVD SUITE 208
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-6301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-254-6070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL STEPHEN PHILLIPS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 864-254-6070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 12544
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------