Provider Demographics
NPI:1164546974
Name:PENINSULA EYE CENTER PA
Entity Type:Organization
Organization Name:PENINSULA EYE CENTER PA
Other - Org Name:PENINSULA EYE SURGEONS PA MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LUPPENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-749-9290
Mailing Address - Street 1:101 MILFORD STREET
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-749-9290
Mailing Address - Fax:410-543-9087
Practice Address - Street 1:101 MILFORD STREET
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-749-9290
Practice Address - Fax:410-543-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207W00000X
MD207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
20885OtherMAMSI-UNITED HEALTH CARE
MD915111700Medicaid
MDH788PEOtherCAREFIRST BLUE SHIELD
T699OtherCAREFIRST BS-FEDERAL
DE0000134502Medicaid
MD915111700Medicaid
DE789836Medicare ID - Type UnspecifiedGROUP #
MDH788Medicare ID - Type UnspecifiedGROUP #