1538161989 NPI number — PREMIER EYE CARE GROUP, INC.

Table of content: (NPI 1538161989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538161989 NPI number — PREMIER EYE CARE GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER EYE CARE GROUP, 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:
1538161989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92 TUSCARORA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17104-1667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-232-0843
Provider Business Mailing Address Fax Number:
717-232-2215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3903 HARTZDALE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMP HILL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-761-3077
Provider Business Practice Location Address Fax Number:
717-761-1186
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRENT
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
717-232-2245

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG000093 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: MD020133E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 6000004226 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 756393 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 747187 . This is a "HIGHMARK BS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 01823136 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01471368 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2276000 . This is a "CAPITAL BC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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