1568480424 NPI number — WEST PHILADELPHIA EYE ASSOC

Table of content: (NPI 1568480424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568480424 NPI number — WEST PHILADELPHIA EYE ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST PHILADELPHIA EYE ASSOC
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:
1568480424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 S 54TH ST
Provider Second Line Business Mailing Address:
SUITE 25
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19143-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-748-0185
Provider Business Mailing Address Fax Number:
215-748-0180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 S 54TH ST
Provider Second Line Business Practice Location Address:
SUITE 25
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19143-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-748-0185
Provider Business Practice Location Address Fax Number:
215-748-0180
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUONG
Authorized Official First Name:
DAT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
215-748-0185

Provider Taxonomy Codes

  • Taxonomy code: 152WX0102X , with the licence number:  OEG000507 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1435485 . This is a "PERSONAL CHOICE/BLUE CHOI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2119844000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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