Provider Demographics
NPI:1093714420
Name:NEURO-OPHTHALMOLOGIC ASSOCIATES PC
Entity Type:Organization
Organization Name:NEURO-OPHTHALMOLOGIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:SERGOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-928-3130
Mailing Address - Street 1:840 WALNUT ST
Mailing Address - Street 2:SUITE 930
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-928-3130
Mailing Address - Fax:215-592-1923
Practice Address - Street 1:840 WALNUT ST
Practice Address - Street 2:SUITE 930
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-928-3130
Practice Address - Fax:215-592-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031030L207W00000X
207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000252102Medicaid
PA000688737Medicaid
0060163000OtherINDEPENDENCE BLUE CROSS
PA039391OtherHIGHMARK BLUE SHIELD
NJ3528804Medicaid
DE006013Medicare PIN
PA039391Medicare PIN
NJ3528804Medicaid
DE490562Medicare PIN
PA000688737Medicaid