Provider Demographics
NPI:1962571380
Name:CLEVELAND EYE CLINIC PA
Entity type:Organization
Organization Name:CLEVELAND EYE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMETT
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-846-6641
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732
Mailing Address - Country:US
Mailing Address - Phone:662-846-6641
Mailing Address - Fax:662-846-6644
Practice Address - Street 1:136 NORTH STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-846-6641
Practice Address - Fax:662-846-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS546152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09957099Medicaid
T21133Medicare UPIN
0289000001Medicare NSC