Provider Demographics
NPI:1417564592
Name:RIDLEY CREEK RETINA LLC
Entity Type:Organization
Organization Name:RIDLEY CREEK RETINA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-892-1708
Mailing Address - Street 1:200 E STATE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3434
Mailing Address - Country:US
Mailing Address - Phone:610-892-1708
Mailing Address - Fax:610-892-8766
Practice Address - Street 1:200 E STATE ST STE 105
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3434
Practice Address - Country:US
Practice Address - Phone:610-892-1708
Practice Address - Fax:610-892-8766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Multi-Specialty