Provider Demographics
NPI:1518939511
Name:MEDIVISION, PA
Entity Type:Organization
Organization Name:MEDIVISION, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:H
Authorized Official - Last Name:CROWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-638-9505
Mailing Address - Street 1:105 N EARLE ST
Mailing Address - Street 2:
Mailing Address - City:WALHALLA
Mailing Address - State:SC
Mailing Address - Zip Code:29691-2419
Mailing Address - Country:US
Mailing Address - Phone:864-985-0691
Mailing Address - Fax:864-638-9979
Practice Address - Street 1:105 N EARLE ST
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:SC
Practice Address - Zip Code:29691-2419
Practice Address - Country:US
Practice Address - Phone:864-985-0691
Practice Address - Fax:864-638-9979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0507152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9882Medicaid
SC1278480001OtherMEDICARE DME
SC1278480001OtherMEDICARE DME
SC1278480001Medicare NSC