=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861909707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ICE OPHTHALMOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2017
-----------------------------------------------------
Last Update Date | 09/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2141 MENTOR AVE
-----------------------------------------------------
City | PAINESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44077-1323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-354-6900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2141 MENTOR AVE
-----------------------------------------------------
City | PAINESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44077-1323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SEEMA ICE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 330-281-3009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 09339
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------