Provider Demographics
NPI:1568655389
Name:PREMIER OPHTHALMOLOGY, PLC
Entity Type:Organization
Organization Name:PREMIER OPHTHALMOLOGY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVILACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-340-8383
Mailing Address - Street 1:477 VIKING DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7349
Mailing Address - Country:US
Mailing Address - Phone:757-340-8383
Mailing Address - Fax:
Practice Address - Street 1:477 VIKING DR
Practice Address - Street 2:SUITE 110
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7349
Practice Address - Country:US
Practice Address - Phone:757-340-8383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232988207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA437139OtherANTHEM BCBS
VA437140OtherANTHEM BCBS
VA437139OtherANTHEM BCBS