Provider Demographics
NPI:1063444123
Name:RETINA VITREOUS CONSULTANTS INC.
Entity Type:Organization
Organization Name:RETINA VITREOUS CONSULTANTS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-926-1580
Mailing Address - Street 1:300 OXFORD DR
Mailing Address - Street 2:STE 300
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-2361
Mailing Address - Country:US
Mailing Address - Phone:412-683-5300
Mailing Address - Fax:412-349-8655
Practice Address - Street 1:300 OXFORD DR
Practice Address - Street 2:STE 300
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-2361
Practice Address - Country:US
Practice Address - Phone:412-683-5300
Practice Address - Fax:412-349-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010550120005Medicaid
PA0010550120005Medicaid