MEDICARE: EYE PHYSICIANS OF SPRINGFIELD, 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	207W00000X	Ophthalmology Physician		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952315939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE PHYSICIANS OF SPRINGFIELD, INC

Provider Business Mailing Address
First Line	:	2254 OLYMPIC ST
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45503-2737
Country	:	US
Telephone Number	:	937-399-8287
Fax Number	:	937-399-1670

Provider Business Practice Location Address
First Line	:	2254 OLYMPIC ST
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45503-2737
Country	:	US
Telephone Number	:	937-399-8287
Fax Number	:	937-399-1670

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JERRY K SHELL
Credential	:	MD
Telephone Number	:	937-399-8287

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	07/21/2022

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