Provider Demographics
NPI:1093769911
Name:EBECK, ELMER W (OD)
Entity Type:Individual
Prefix:
First Name:ELMER
Middle Name:W
Last Name:EBECK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SMITH DR STE 3
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-4129
Mailing Address - Country:US
Mailing Address - Phone:724-776-5888
Mailing Address - Fax:724-935-2900
Practice Address - Street 1:101 SMITH DR STE 3
Practice Address - Street 2:
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-4129
Practice Address - Country:US
Practice Address - Phone:724-776-5888
Practice Address - Fax:724-935-2900
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA402114Medicare PIN
PA0278200001Medicare NSC
PAT30170Medicare UPIN