Provider Demographics
NPI:1568664506
Name:VISION QUEST MEDICAL CENTER, PA
Entity Type:Organization
Organization Name:VISION QUEST MEDICAL CENTER, PA
Other - Org Name:SONNTAG EYE ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:MONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-377-3937
Mailing Address - Street 1:5680 W GAGE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1326
Mailing Address - Country:US
Mailing Address - Phone:208-377-3937
Mailing Address - Fax:208-377-9455
Practice Address - Street 1:3025 W CHERRY LN
Practice Address - Street 2:SUITE 207
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1125
Practice Address - Country:US
Practice Address - Phone:208-898-1614
Practice Address - Fax:208-898-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100002152W00000X
IDODP-100417152W00000X
IDO-0860207W00000X
IDM4623207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID46235OtherBLUE CROSS GROUP NO
ID001553800Medicaid
ID807072300Medicaid
ID000160500Medicaid
ID806834700Medicaid
ID807072200Medicaid
ID1594247Medicare PIN
ID1375000Medicare ID - Type UnspecifiedMEDICARE GROUP NO
ID807072300Medicaid
ID000160500Medicaid
ID46235OtherBLUE CROSS GROUP NO
B63621Medicare UPIN
ID807072200Medicaid
ID1591024Medicare PIN