Provider Demographics
NPI:1003978180
Name:SOUTH BALTIMORE EYE ASSOCITATE INC.
Entity Type:Organization
Organization Name:SOUTH BALTIMORE EYE ASSOCITATE INC.
Other - Org Name:FEDERAL HILL EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CALVERT
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:BREGEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:410-752-8208
Mailing Address - Street 1:1029 LIGHT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4017
Mailing Address - Country:US
Mailing Address - Phone:410-752-8208
Mailing Address - Fax:410-752-7144
Practice Address - Street 1:1029 LIGHT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-4017
Practice Address - Country:US
Practice Address - Phone:410-752-8208
Practice Address - Fax:410-752-7144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0876152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD07883OtherSPECTERA
MD1084940001OtherMEDICARE DME
MD50383OtherMAMSI OPT CHOICE
MD52142903OtherBLUE CROSS
MD90492OtherBLOCK
MD50349OtherDAVIS
MD210070OtherNVA
MD331OtherBALTIMORE CITY VISION
MDAS12101560001OtherCIGNA
MD210070OtherNVA
MD=========OtherEHP
MD331OtherBALTIMORE CITY VISION
MD90492OtherBLOCK
MD07883OtherSPECTERA