Provider Demographics
NPI:1407347602
Name:INTELERETINA PROFESSIONAL GROUP LLC
Entity Type:Organization
Organization Name:INTELERETINA PROFESSIONAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-277-6816
Mailing Address - Street 1:PO BOX 31000
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96849-5769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 S KING ST STE 218B
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1703
Practice Address - Country:US
Practice Address - Phone:808-744-5189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty