MEDICARE: KIES EYE CENTER, LLC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC6364	OTHER	MO	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	105645	OTHER	MO	BLUECROSS BLUE SHIELD

General Provider Information

NPI Number	:	1376505248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIES EYE CENTER, LLC

Provider Business Mailing Address
First Line	:	1429 N MOUNT AUBURN RD
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-2171
Country	:	US
Telephone Number	:	573-335-9175
Fax Number	:	573-334-3390

Provider Business Practice Location Address
First Line	:	1429 N MOUNT AUBURN RD
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-2171
Country	:	US
Telephone Number	:	573-335-9175
Fax Number	:	573-334-3390

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	DAVID C ANDERSON
Credential	:
Telephone Number	:	573-335-9175

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	10/03/2007

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Directions to “KIES EYE CENTER, LLC ” Practice Location

Language	Start Address	Practice Location

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