MEDICARE: MUSKOGEE REGIONAL EYE CLINIC INC

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	174400000X	Specialist	11682	OK

General Provider Information

NPI Number	:	1316069008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MUSKOGEE REGIONAL EYE CLINIC INC

Provider Business Mailing Address
First Line	:	329 S 38TH ST
Second Line	:
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-4945
Country	:	US
Telephone Number	:	918-687-9998
Fax Number	:	918-687-4135

Provider Business Practice Location Address
First Line	:	329 S 38TH ST
Second Line	:
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-4945
Country	:	US
Telephone Number	:	918-687-9998
Fax Number	:	918-687-4135

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL L SOPER
Credential	:	M.D.
Telephone Number	:	918-687-9998

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	04/20/2008

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