1124253398 NPI number — G B FISHER III DO PA

Table of content: (NPI 1124253398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124253398 NPI number — G B FISHER III DO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G B FISHER III DO PA
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:
FISHER EYE 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:
1124253398
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
875 105TH AVE NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-431-7070
Provider Business Mailing Address Fax Number:
239-431-7075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
875 105 AVE NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-431-7070
Provider Business Practice Location Address Fax Number:
239-431-7075
Provider Enumeration Date:
05/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FISHER
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
BRIT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
239-431-7070

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  OS7853 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 49530 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 256757100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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