Provider Demographics
NPI:1588963508
Name:EYE PHYSICIAN ASSOCIATES, S.C.
Entity type:Organization
Organization Name:EYE PHYSICIAN ASSOCIATES, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-385-8725
Mailing Address - Street 1:2801 W KK RIVER PKWY
Mailing Address - Street 2:SUITE 170
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3669
Mailing Address - Country:US
Mailing Address - Phone:414-385-8725
Mailing Address - Fax:414-385-8730
Practice Address - Street 1:2801 W KK RIVER PKWY
Practice Address - Street 2:SUITE 170
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-385-8725
Practice Address - Fax:414-385-8730
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE PHYSICIAN ASSOCIATES, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32306500Medicaid
WI31912700Medicaid
WI38632200Medicaid
WI34678800Medicaid
WI30934200Medicaid
WI32735700Medicaid
WI34249800Medicaid
WIC017777OtherRR MEDICARE
WI000073822OtherMILWAUKEE PTAN
WI1851590343Medicaid
WIC017777OtherRR MEDICARE