1174726210 NPI number — DRAISIN VISION GROUP PA

Table of content: (NPI 1174726210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174726210 NPI number — DRAISIN VISION GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRAISIN VISION GROUP 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:
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:
1174726210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80817
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29416-0817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-556-2020
Provider Business Mailing Address Fax Number:
843-763-3937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1470 TOBIAS GADSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29407-4707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-556-2020
Provider Business Practice Location Address Fax Number:
843-763-3937
Provider Enumeration Date:
06/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BESSINGER
Authorized Official First Name:
BRIDGET
Authorized Official Middle Name:
KELLY
Authorized Official Title or Position:
ADMIN ASSIST
Authorized Official Telephone Number:
843-556-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  503 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 1413 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WC0802X , with the licence number: 503 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WC0802X , with the licence number: 1413 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WL0500X , with the licence number: 1413 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WS0006X , with the licence number: 503 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: 503 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: D05037 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1548226822 . This is a "NDRAISIN NPI #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1730305434 . This is a "J SMITH'S NPI #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".