MEDICARE: PREMIER EYE CLINIC

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	ME96155	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265718894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER EYE CLINIC

Provider Business Mailing Address
First Line	:	3641 SOUTH CLYDE MORRIS BOULEVARD
Second Line	:	SUITE 500
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-2357
Country	:	US
Telephone Number	:	386-788-6198
Fax Number	:	386-788-4616

Provider Business Practice Location Address
First Line	:	3641 SOUTH CLYDE MORRIS BOULEVARD
Second Line	:	SUITE 500
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-2357
Country	:	US
Telephone Number	:	386-788-6198
Fax Number	:	386-788-4616

Authorized Official
Title or Position	:	PRESIDENT
Name	:	QING GE
Credential	:	M.D., PHD.
Telephone Number	:	386-788-6198

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	07/10/2012

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Directions to “PREMIER EYE CLINIC ” Practice Location

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