MEDICARE: THE RETINA INSTITUTE 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	N/A	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	541	OTHER	MO	BCBS
2	04121950	OTHER	IL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407858673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE RETINA INSTITUTE LLC

Provider Business Mailing Address
First Line	:	1600 S BRENTWOOD BLVD
Second Line	:	STE 800
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-1317
Country	:	US
Telephone Number	:	314-367-1181
Fax Number	:	314-968-5117

Provider Business Practice Location Address
First Line	:	4921 PARKVIEW PL
Second Line	:	STE 12B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-1032
Country	:	US
Telephone Number	:	314-367-1181
Fax Number	:	314-968-5117

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. M GILBERT GRAND
Credential	:	M.D.
Telephone Number	:	314-367-1181

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	01/23/2009

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Directions to “THE RETINA INSTITUTE LLC ” Practice Location

Language	Start Address	Practice Location

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