Provider Demographics
NPI:1396718318
Name:DOVER OPHTHALMOLOGY ASC, LLC
Entity type:Organization
Organization Name:DOVER OPHTHALMOLOGY ASC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:20 BURTON HILLS BLVD.
Mailing Address - Street 2:SUITE 500, ATTN: L&C
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6176
Mailing Address - Country:US
Mailing Address - Phone:615-665-1283
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:655 S BAY RD
Practice Address - Street 2:SUITE 5B
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4615
Practice Address - Country:US
Practice Address - Phone:302-678-4688
Practice Address - Fax:302-678-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEFSSC-005261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE001148628Medicaid
DE001148628Medicaid
DE08-C0001008Medicare Oscar/Certification
DE490005092Medicare PIN