1003978180 NPI number — SOUTH BALTIMORE EYE ASSOCITATE INC.

Table of content: (NPI 1003978180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003978180 NPI number — SOUTH BALTIMORE EYE ASSOCITATE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH BALTIMORE EYE ASSOCITATE 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:
6
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:
1003978180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1029 LIGHT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21230-4017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-752-8208
Provider Business Mailing Address Fax Number:
410-752-7144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1029 LIGHT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21230-4017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-752-8208
Provider Business Practice Location Address Fax Number:
410-752-7144
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREGEL
Authorized Official First Name:
CALVERT
Authorized Official Middle Name:
ROSS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-752-8208

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TA0876 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07883 . This is a "SPECTERA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1084940001 . This is a "MEDICARE DME" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 50383 . This is a "MAMSI OPT CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 52142903 . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 90492 . This is a "BLOCK" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 50349 . This is a "DAVIS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 210070 . This is a "NVA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 331 . This is a "BALTIMORE CITY VISION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: AS12101560001 . This is a "CIGNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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