1285661454 NPI number — GALLOWAY REGIONAL EYE CENTER PA

Table of content: (NPI 1285661454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285661454 NPI number — GALLOWAY REGIONAL EYE CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GALLOWAY REGIONAL EYE CENTER 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:
1285661454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 49847
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29649-0015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-943-2010
Provider Business Mailing Address Fax Number:
964-323-0345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 OVERLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29646-4069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-943-2010
Provider Business Practice Location Address Fax Number:
864-323-0345
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GALLOWAY
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
864-943-2010

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  29742 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 7563 , 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: GP4102 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF8980 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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