Provider Demographics
NPI:1225371255
Name:AEG PENNSYLVANIA PROFESSIONAL, INC
Entity Type:Organization
Organization Name:AEG PENNSYLVANIA PROFESSIONAL, INC
Other - Org Name:EYETIQUE -CRANBERRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-620-1186
Mailing Address - Street 1:111 E 4TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6206
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:314-741-4947
Practice Address - Street 1:802A WARRENDALE VILLAGE DRIVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WARRENDALE
Practice Address - State:PA
Practice Address - Zip Code:15086
Practice Address - Country:US
Practice Address - Phone:724-772-2222
Practice Address - Fax:314-741-4947
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AEG PENNSYLVANIA PROFESSIONAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-28
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty