1760490494 NPI number — BROOKHAVEN FAMILY EYE CARE CENTER

Table of content: (NPI 1760490494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760490494 NPI number — BROOKHAVEN FAMILY EYE CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKHAVEN FAMILY EYE CARE CENTER
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:
BROOKHAVEN VISION SOURCE
Provider Other Organization Name Type Code:
3
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:
1760490494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4106 EDGMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKHAVEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19015-2314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-872-8989
Provider Business Mailing Address Fax Number:
610-872-5220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4106 EDGMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKHAVEN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19015-2314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-872-8989
Provider Business Practice Location Address Fax Number:
610-872-5220
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DE JESSE
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
610-872-8989

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG001547 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: OEG001547 , 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: 2115330000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CM9120 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001429488 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5498366 . This is a "AETNA UNIVERSAL GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2628516 . This is a "AETNA GROUP HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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