1184759102 NPI number — FANELLI EYE ASSOCIATES,OD, PA.

Table of content: TYLER WILLIAM RUSSELL CRNA (NPI 1447889548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184759102 NPI number — FANELLI EYE ASSOCIATES,OD, PA.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FANELLI EYE ASSOCIATES,OD, 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:
1184759102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5526B CAROLINA BEACH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28412-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-452-7225
Provider Business Mailing Address Fax Number:
910-452-7229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5526B CAROLINA BEACH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28412-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-452-7225
Provider Business Practice Location Address Fax Number:
910-452-7229
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FANELLI
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
LOUIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-452-7225

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1188 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89012YT , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09077 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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