MEDICARE: PREMIER EYE SURGERY LLC

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	261QS0132X	Ophthalmologic Surgery Clinic/Center
2	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1932819836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER EYE SURGERY LLC

Provider Business Mailing Address
First Line	:	3641 CLYDE MORRIS BLVD STE 500
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-2357
Country	:	US
Telephone Number	:	386-788-6198
Fax Number	:

Provider Business Practice Location Address
First Line	:	3641 CLYDE MORRIS BLVD STE 500
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-2357
Country	:	US
Telephone Number	:	386-788-6198
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	QING GE
Credential	:	MD
Telephone Number	:	386-788-6198

Provider Enumeration Date	:	12/01/2022
Last Update Date	:	08/22/2023

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Directions to “PREMIER EYE SURGERY LLC ” Practice Location

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