Provider Demographics
NPI:1275835829
Name:SHANNON M. BURGESS, OD
Entity Type:Organization
Organization Name:SHANNON M. BURGESS, OD
Other - Org Name:VALLEY FORGE EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:610-917-0700
Mailing Address - Street 1:1260 VALLEY FORGE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-2691
Mailing Address - Country:US
Mailing Address - Phone:610-917-0700
Mailing Address - Fax:610-917-0708
Practice Address - Street 1:1260 VALLEY FORGE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-2691
Practice Address - Country:US
Practice Address - Phone:610-917-0700
Practice Address - Fax:610-917-0708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000127261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2013716000OtherKEYSTONE HEALTH PLAN
001321149OtherBLUE SHIELD
50004981OtherCAPITAL BLUE CROSS
001321149OtherBLUE SHIELD
2013716000OtherKEYSTONE HEALTH PLAN