Provider Demographics
NPI:1396054458
Name:SOUTHSIDE EYE CENTER, P.C.
Entity type:Organization
Organization Name:SOUTHSIDE EYE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELMORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-883-2020
Mailing Address - Street 1:1634 W SMITH VALLEY RD STE A
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1550
Mailing Address - Country:US
Mailing Address - Phone:317-883-2020
Mailing Address - Fax:317-883-2059
Practice Address - Street 1:1634 W SMITH VALLEY RD STE A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1550
Practice Address - Country:US
Practice Address - Phone:317-883-2020
Practice Address - Fax:317-883-2059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003454152WC0802X, 152WL0500X, 152WP0200X, 152WV0400X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM100036991Medicare PIN
INDS1108Medicare PIN