Provider Demographics
NPI:1215083506
Name:THE RETINA GROUP, PLLC
Entity type:Organization
Organization Name:THE RETINA GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PLLC MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-898-3937
Mailing Address - Street 1:6262 E BROADWAY RD
Mailing Address - Street 2:STE 106
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6262 E BROADWAY RD
Practice Address - Street 2:STE 106
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6101
Practice Address - Country:US
Practice Address - Phone:480-898-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-27
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
74300Medicare ID - Type Unspecified