1801849427 NPI number — MAIN STREET ASC LLC

Table of content: (NPI 1801849427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801849427 NPI number — MAIN STREET ASC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET ASC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OPHTHALMIC ASSOCIATES SURGERY AND LASER CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801849427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1318 EISENHOWER BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15904-3307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-266-5795
Provider Business Mailing Address Fax Number:
814-266-5793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1318 EISENHOWER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15904-3307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-536-5343
Provider Business Practice Location Address Fax Number:
814-536-1525
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLITO
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT GOVERNING BODY
Authorized Official Telephone Number:
814-266-5795

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  APPLIED , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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