Provider Demographics
NPI:1043297385
Name:RETINA CENTER OF WESTERN MARYLAND
Entity Type:Organization
Organization Name:RETINA CENTER OF WESTERN MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARA
Authorized Official - Middle Name:
Authorized Official - Last Name:TASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-416-8600
Mailing Address - Street 1:251 E BALTIMORE ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6144
Mailing Address - Country:US
Mailing Address - Phone:301-416-8600
Mailing Address - Fax:301-416-8602
Practice Address - Street 1:251 E BALTIMORE ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6144
Practice Address - Country:US
Practice Address - Phone:301-416-8600
Practice Address - Fax:301-416-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052418207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD170200900Medicaid
MD170200900Medicaid
F41502Medicare UPIN