1528119492 NPI number — ADVANCED VISION ASSOCIATES LLC

Table of content: (NPI 1528119492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528119492 NPI number — ADVANCED VISION ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED VISION ASSOCIATES LLC
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:
1528119492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4405 BELLEMEADE AVE
Provider Second Line Business Mailing Address:
STE. 101
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47714-0682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-474-1010
Provider Business Mailing Address Fax Number:
812-485-2476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4405 BELLEMEADE AVE
Provider Second Line Business Practice Location Address:
STE. 101
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47714-0682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-474-1010
Provider Business Practice Location Address Fax Number:
812-485-2476
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CROWLEY
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-474-1010

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  01029433 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000181187 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 231380 . This is a "MEDICARE SECONDARY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 180040683 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200316700 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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