1174726210 NPI number — DRAISIN VISION GROUP PA

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 1174726210 NPI number — DRAISIN VISION GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRAISIN VISION GROUP PA
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:
1174726210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80817
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29416-0817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-556-2020
Provider Business Mailing Address Fax Number:
843-763-3937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1470 TOBIAS GADSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29407-4707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-556-2020
Provider Business Practice Location Address Fax Number:
843-763-3937
Provider Enumeration Date:
06/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BESSINGER
Authorized Official First Name:
BRIDGET
Authorized Official Middle Name:
KELLY
Authorized Official Title or Position:
ADMIN ASSIST
Authorized Official Telephone Number:
843-556-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1413 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WC0802X , with the licence number: 503 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WC0802X , with the licence number: 1413 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WL0500X , with the licence number: 1413 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WS0006X , with the licence number: 503 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: 503 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 503 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D05037 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1548226822 . This is a "NDRAISIN NPI #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1730305434 . This is a "J SMITH'S NPI #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".