=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982797007
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RETINA PHYSICIANS & SURGEONS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 10/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 89 SYLVANIA DR 2ND FL
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45440-3281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-427-8900
-----------------------------------------------------
Fax | 937-427-1710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 89 SYLVANIA DR 2ND FL
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45440-3281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-427-8900
-----------------------------------------------------
Fax | 937-427-1710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALS MANAGER
-----------------------------------------------------
Name | TERI KNIGHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-569-3741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------