Provider Demographics
NPI:1174603872
Name:EYE CENTER NORTHEAST
Entity type:Organization
Organization Name:EYE CENTER NORTHEAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:ARNOLD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:207-947-1291
Mailing Address - Street 1:417 STATE ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6620
Mailing Address - Country:US
Mailing Address - Phone:207-947-1291
Mailing Address - Fax:207-947-9241
Practice Address - Street 1:417 STATE ST
Practice Address - Street 2:SUITE 230
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6620
Practice Address - Country:US
Practice Address - Phone:207-947-1291
Practice Address - Fax:207-947-9241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1042060OtherAETNA
ME114630000Medicaid
ME114630100Medicaid
ME114630100Medicaid
ME0736390001Medicare NSC