1811059306 NPI number — PENINSULA EYE CENTER, P.A

Table of content: (NPI 1811059306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811059306 NPI number — PENINSULA EYE CENTER, P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA EYE CENTER, P.A
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:
1811059306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 MILFORD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21804-6952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-749-9290
Provider Business Mailing Address Fax Number:
410-543-9087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 MILFORD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21804-6952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-749-9290
Provider Business Practice Location Address Fax Number:
410-543-9087
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NOCK
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
410-749-9290

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  A1060 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 213769 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57466701 . This is a "CAREFIRST BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 6800028 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2353563 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 45227 . This is a "COVENTRY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5575535 . This is a "AETNA NON-HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 778441400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH5 . This is a "CAREFIRST BLUE CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0000464928 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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