Provider Demographics
NPI:1962561183
Name:ELYRIA EYE CLINIC INC
Entity type:Organization
Organization Name:ELYRIA EYE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:H
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-366-9411
Mailing Address - Street 1:850 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6559
Mailing Address - Country:US
Mailing Address - Phone:440-366-9411
Mailing Address - Fax:440-366-9403
Practice Address - Street 1:850 E BROAD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6559
Practice Address - Country:US
Practice Address - Phone:440-366-9411
Practice Address - Fax:440-366-9403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051885207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0592701Medicaid
OH0592701Medicaid
OHA16107Medicare UPIN