MEDICARE: SOUTHERN VISION CENTER, 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	152W00000X	Optometrist	3605	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	281566897004	OTHER	OH	MEDICAL MUTUAL
2	000000120727	OTHER	OH	ANTHEM
3	1184130001	OTHER	OH	DMERC
4	2200190	OTHER	OH	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1821108192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN VISION CENTER, INC.

Provider Business Mailing Address
First Line	:	105 GREAT SOUTHERN BLVD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43207-4001
Country	:	US
Telephone Number	:	614-491-3435
Fax Number	:	614-491-1699

Provider Business Practice Location Address
First Line	:	105 GREAT SOUTHERN BLVD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43207-4001
Country	:	US
Telephone Number	:	614-491-3435
Fax Number	:	614-491-1699

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	MR. MICHAEL P GILILAND
Credential	:	O.D.
Telephone Number	:	614-491-3435

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	12/07/2007

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Directions to “SOUTHERN VISION CENTER, INC. ” Practice Location

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