1730103946 NPI number — DR. DIANE G FRIES-BALOG O.D.

Table of content: DR. DIANE G FRIES-BALOG O.D. (NPI 1730103946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730103946 NPI number — DR. DIANE G FRIES-BALOG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRIES-BALOG
Provider First Name:
DIANE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1730103946
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
531 N CHARLOTTE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTTSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19464-4602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-323-0450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
531 N CHARLOTTE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTTSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19464-4602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-323-0450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG001588 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 27OA00519300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: NJ1588 . This is a "EYEMED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 766110 . This is a "HIGHMARK BC/BS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: PA77433-1 . This is a "VISION BENEFITS OF AMERICA (VBA)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0018193600003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4390338 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1105628 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 55470 . This is a "DAVISVISION" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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