MEDICARE: BROADWAY EYE CARE ASSOCIATES, PSC

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

General Provider Information

NPI Number	:	1649431560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY EYE CARE ASSOCIATES, PSC

Provider Business Mailing Address
First Line	:	PO BOX 11744
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40251-0744
Country	:	US
Telephone Number	:	502-772-3625
Fax Number	:	502-772-3037

Provider Business Practice Location Address
First Line	:	2600 W BROADWAY STE 105
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40211-1303
Country	:	US
Telephone Number	:	502-772-3625
Fax Number	:	502-772-3037

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	DR. SHORYE PAYNE
Credential	:	M.D.
Telephone Number	:	502-772-3625

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	06/23/2008

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