Provider Demographics
NPI:1316102726
Name:CENTRAL PLAINS EYE MDS, LLC
Entity type:Organization
Organization Name:CENTRAL PLAINS EYE MDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:316-712-4970
Mailing Address - Street 1:7717 E 29TH ST N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-3443
Mailing Address - Country:US
Mailing Address - Phone:316-712-4970
Mailing Address - Fax:316-712-4987
Practice Address - Street 1:7717 E 29TH ST N STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-3444
Practice Address - Country:US
Practice Address - Phone:316-712-4970
Practice Address - Fax:316-712-4987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic SurgeryGroup - Multi-Specialty
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSE38659Medicare UPIN