MEDICARE: SIEGMUND EYE CARE PA

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	SC1389	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1073675690	OTHER	SC	INDIVIDUAL NPI - JASON
2	1528120144	OTHER	SC	INDIVIDUAL NPI - KELLE

General Provider Information

NPI Number	:	1912021759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIEGMUND EYE CARE PA

Provider Business Mailing Address
First Line	:	4278 RIVER OAKS DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-5603
Country	:	US
Telephone Number	:	843-796-1155
Fax Number	:	843-796-1153

Provider Business Practice Location Address
First Line	:	4278 RIVER OAKS DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-5603
Country	:	US
Telephone Number	:	843-796-1155
Fax Number	:	843-796-1153

Authorized Official
Title or Position	:	OWNER
Name	:	JASON SIEGMUND
Credential	:	OD
Telephone Number	:	843-796-1155

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	01/28/2015

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