1780879510 NPI number — RIVERSIDE EYE CENTER PA

Table of content: (NPI 1780879510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780879510 NPI number — RIVERSIDE EYE CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE 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:
1780879510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
193 MAIN ST
Provider Second Line Business Mailing Address:
RIVERSIDE EYE CENTER
Provider Business Mailing Address City Name:
NORWAY
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04268-5645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-743-0027
Provider Business Mailing Address Fax Number:
207-743-0051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 LISBON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04240-7418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-786-2500
Provider Business Practice Location Address Fax Number:
207-786-2503
Provider Enumeration Date:
09/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FOURNIER
Authorized Official First Name:
JANICE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
207-786-1917

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  015596 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00184354 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061139 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 325120099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431545400 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: NX3033 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: M2307901 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: MM8909 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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