Provider Demographics
NPI:1336101617
Name:GEORGE E FAVA MD PC
Entity Type:Organization
Organization Name:GEORGE E FAVA MD PC
Other - Org Name:FAVA & MARIA EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:FAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-272-2010
Mailing Address - Street 1:875 NORMAN DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7454
Mailing Address - Country:US
Mailing Address - Phone:717-272-2010
Mailing Address - Fax:717-272-2937
Practice Address - Street 1:875 NORMAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7454
Practice Address - Country:US
Practice Address - Phone:717-272-2010
Practice Address - Fax:717-272-2937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
542760Medicare ID - Type Unspecified