Provider Demographics
NPI:1528080876
Name:FRY EYE SURGERY CENTER, LLC
Entity type:Organization
Organization Name:FRY EYE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-275-7248
Mailing Address - Street 1:411 CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-6124
Mailing Address - Country:US
Mailing Address - Phone:620-276-7699
Mailing Address - Fax:620-276-7704
Practice Address - Street 1:411 CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-6124
Practice Address - Country:US
Practice Address - Phone:620-276-7699
Practice Address - Fax:620-276-7704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100750170AMedicaid
CO94510021Medicaid
KS100305010AMedicaid
KS490003540Medicare ID - Type UnspecifiedRR MEDICARE
KS100305010AMedicaid
CO94510021Medicaid