1073621728 NPI number — LOGIC EYECARE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073621728 NPI number — LOGIC EYECARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGIC EYECARE INC
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:
Provider Other Organization Name Type Code:
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:
1073621728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1137 E MOUNT PLEASANT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19150-2901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-548-2010
Provider Business Mailing Address Fax Number:
215-548-2130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6101 LIMEKILN PIKE
Provider Second Line Business Practice Location Address:
MEDICAL SUITE
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-548-2010
Provider Business Practice Location Address Fax Number:
215-548-2130
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HILL- BENNETT
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
215-548-2010

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG000255 , 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)

  • Identifier: 223752000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00010192 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 097332 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20189 . This is a "AMERICHOICE/SPECTERA VISI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: LH529261 . This is a "BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0019658780001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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