Provider Demographics
NPI:1548366958
Name:MID STATE EYE ASSOCIATES
Entity type:Organization
Organization Name:MID STATE EYE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:VARNUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-465-9500
Mailing Address - Street 1:840 KENNEDY MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OAKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04963
Mailing Address - Country:US
Mailing Address - Phone:207-465-9500
Mailing Address - Fax:207-465-9500
Practice Address - Street 1:840 KENNEDY MEMORIAL DRIVE
Practice Address - Street 2:SUITE 2
Practice Address - City:OAKLAND
Practice Address - State:ME
Practice Address - Zip Code:04963
Practice Address - Country:US
Practice Address - Phone:207-465-9500
Practice Address - Fax:207-465-9500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT747152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMM9180Medicare PIN
4954980001Medicare NSC