1205292463 NPI number — OPHTHALMOLOGY AND RETINA ASSOCIATES, LLC

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 1205292463 NPI number — OPHTHALMOLOGY AND RETINA ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPHTHALMOLOGY AND RETINA ASSOCIATES, 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:
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:
1205292463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4576
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26504-4576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-750-2576
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
WAYNESBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15370-1660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-852-3008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TIRGAN
Authorized Official First Name:
NIMA
Authorized Official Middle Name:
Authorized Official Title or Position:
OPHTHALMOLOGIST
Authorized Official Telephone Number:
409-750-2576

Provider Taxonomy Codes

  • Taxonomy code: 261QS0132X , with the licence number:  MD454412 , 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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