Provider Demographics
NPI:1093752495
Name:RETINA DIAGNOSTIC & TREATMENT ASSOCIATES, LLC
Entity Type:Organization
Organization Name:RETINA DIAGNOSTIC & TREATMENT ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-928-3300
Mailing Address - Street 1:840 WALNUT ST
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-928-3300
Mailing Address - Fax:215-825-4723
Practice Address - Street 1:840 WALNUT ST
Practice Address - Street 2:SUITE 1020
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-928-3300
Practice Address - Fax:215-825-4723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101472321-0001Medicaid
PA061323Medicare PIN