Basic Information
| Provider Information | |||||||||
| NPI: | 1184686792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBIA EYE SURGERY CTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60251 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793070 | ||||||||
| FaxNumber: | 8037717639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1920 PICKENS ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793070 | ||||||||
| FaxNumber: | 8037717639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | HIEBERT | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8037793070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | ASF018 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 410166 | 05 | SC | MEDICAID |