MEDICARE: EASTERN VISION GROUP

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	152W00000X	Optometrist	OTDG00506	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2200239	OTHER	RI	UNITED HEALTH
2	872	OTHER	RI	DAVIS VISION
3	79387	OTHER	RI	BLUE CROSSBLUE SHIELD
4	2877	OTHER	RI	NEIGHBORHOOD HEALTH

General Provider Information

NPI Number	:	1407980352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN VISION GROUP

Provider Business Mailing Address
First Line	:	1388 MINERAL SPRING AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02904-4649
Country	:	US
Telephone Number	:	401-353-3230
Fax Number	:	401-353-3236

Provider Business Practice Location Address
First Line	:	1388 MINERAL SPRING AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02904-4649
Country	:	US
Telephone Number	:	401-353-3230
Fax Number	:	401-353-3236

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NORMAANN GERALDINE SWENSON
Credential	:	OD
Telephone Number	:	401-353-3230

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/26/2013

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