Provider Demographics
NPI:1447286059
Name:SOUTHERN OHIO EYE SURGICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:SOUTHERN OHIO EYE SURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DEMICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-773-6347
Mailing Address - Street 1:159 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2526
Mailing Address - Country:US
Mailing Address - Phone:740-773-6347
Mailing Address - Fax:740-773-9093
Practice Address - Street 1:159 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2526
Practice Address - Country:US
Practice Address - Phone:740-773-6347
Practice Address - Fax:740-773-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4930152W00000X
207W00000X
OH35059420D207W00000X
OH35078998E207W00000X
WV22313207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5257400001OtherMEDICARE DME MAC
OH2544367Medicaid
OH2383951Medicaid
OH2383988Medicaid
OH2544367Medicaid
9332288Medicare PIN
9332287Medicare PIN
9332285Medicare PIN
9332283Medicare PIN
9332284Medicare PIN