MEDICARE: PHYSICIAN'S EYE CENTER, 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	:	1902076714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN'S EYE CENTER, PSC

Provider Business Mailing Address
First Line	:	1701 NICHOLASVILLE RD
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1403
Country	:	US
Telephone Number	:	859-278-9373
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 NICHOLASVILLE RD
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1403
Country	:	US
Telephone Number	:	859-278-9373
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. W DOUGLAS BACK
Credential	:	M.D.
Telephone Number	:	859-278-9373

Provider Enumeration Date	:	03/07/2008
Last Update Date	:	03/10/2008

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