Provider Demographics
NPI:1154319143
Name:TALLEY MEDICAL-SURGICAL EYE CARE ASSOCIATES PC
Entity type:Organization
Organization Name:TALLEY MEDICAL-SURGICAL EYE CARE ASSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:N
Authorized Official - Last Name:SOMMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-424-2020
Mailing Address - Street 1:6149 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-9134
Mailing Address - Country:US
Mailing Address - Phone:812-424-2020
Mailing Address - Fax:812-424-3000
Practice Address - Street 1:6149 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715
Practice Address - Country:US
Practice Address - Phone:812-424-2020
Practice Address - Fax:812-424-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN152W00000X
207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100475340AMedicaid
KY7100233100Medicaid
KY7100242070Medicaid
IL0001154319143Medicaid
IL08332022OtherBC/BS ILLINOIS PROV #
KY77903243Medicaid
IN100475340AMedicaid
IN283042OtherHEALTHLINK PROVIDER #
IN622953OtherTRIGON PROV #
KY77903243Medicaid