Provider Demographics
NPI:1447218433
Name:LIBERTY EYE SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:LIBERTY EYE SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SLOCHOWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-673-9231
Mailing Address - Street 1:9122 BLUE GRASS RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-3202
Mailing Address - Country:US
Mailing Address - Phone:215-673-9231
Mailing Address - Fax:215-673-9236
Practice Address - Street 1:9122 BLUE GRASS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-3202
Practice Address - Country:US
Practice Address - Phone:215-673-9231
Practice Address - Fax:215-673-9236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA17401501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3562638OtherAETNA HEALTHCARE
PA0001624000OtherKEYSTONE HMO
PA0001624000OtherBLUE CROSS BLUE SHIELD
PA35387Medicaid
PA100964206001Medicaid
PA30019554Medicaid
PA077418Medicare ID - Type Unspecified
PA30019554Medicaid