MEDICARE: STATE LINE EYE CARE CENTER, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19517011	OTHER	MO	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215978622
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE LINE EYE CARE CENTER, PC

Provider Business Mailing Address
First Line	:	7701 STATE LINE RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-1635
Country	:	US
Telephone Number	:	816-444-2900
Fax Number	:	816-444-3304

Provider Business Practice Location Address
First Line	:	7701 STATE LINE RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-1635
Country	:	US
Telephone Number	:	816-444-2900
Fax Number	:	816-444-3304

Authorized Official
Title or Position	:	SECRETARY/OFFICE MANAGER
Name	:	LILLIAM (LILY) S YOHN
Credential	:
Telephone Number	:	816-444-2900

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	03/03/2015

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