1548477821 NPI number — CEDARVILLE EYE ASSOCIATES PC

Table of content: (NPI 1548477821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548477821 NPI number — CEDARVILLE EYE ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDARVILLE EYE ASSOCIATES PC
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:
1548477821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2277 STATE RD
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360-7111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-837-3790
Provider Business Mailing Address Fax Number:
508-833-3551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2277 STATE RD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02360-7111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-888-6393
Provider Business Practice Location Address Fax Number:
508-833-3551
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHURCHILL
Authorized Official First Name:
HARRY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
508-837-3790

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3288 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 151342 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W20418 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0391824 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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