Provider Demographics
NPI:1235378688
Name:PHILADELPHIA VISION CENTER OF ERIE AVE INC
Entity Type:Organization
Organization Name:PHILADELPHIA VISION CENTER OF ERIE AVE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:215-223-5000
Mailing Address - Street 1:1348 W ERIE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4254
Mailing Address - Country:US
Mailing Address - Phone:215-223-5000
Mailing Address - Fax:215-223-9180
Practice Address - Street 1:1348 W ERIE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4254
Practice Address - Country:US
Practice Address - Phone:215-223-5000
Practice Address - Fax:215-223-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA003502332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028724530001Medicaid
PA6176920001Medicare NSC