1669435582 NPI number — PENNWOOD OPHTHALMIC ASSOCIATES, PC

Table of content: (NPI 1669435582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669435582 NPI number — PENNWOOD OPHTHALMIC ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENNWOOD OPHTHALMIC ASSOCIATES, PC
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:
1669435582
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15537-7022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-623-1969
Provider Business Mailing Address Fax Number:
814-623-5590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15537-7022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-623-1969
Provider Business Practice Location Address Fax Number:
814-623-5590
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ERLICHMAN
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
CORMAN
Authorized Official Title or Position:
PRESIDENT/OPHTHALMOLOGY
Authorized Official Telephone Number:
814-623-1969

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 172307 . This is a "BCBS GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012470110004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0016242330004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 172508 . This is a "BCBS GROUP DR SHUKE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0011646070005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB2806 . This is a "RAILROAD MCARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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