Provider Demographics
NPI:1578664959
Name:PHILADELPHIA VISION ASSOCIATES GROUP PRACTICE LLC
Entity Type:Organization
Organization Name:PHILADELPHIA VISION ASSOCIATES GROUP PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-491-2127
Mailing Address - Street 1:1516 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4401
Mailing Address - Country:US
Mailing Address - Phone:215-546-0493
Mailing Address - Fax:610-337-2133
Practice Address - Street 1:1516 LOCUST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-546-0493
Practice Address - Fax:610-337-2133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA95199Medicare ID - Type Unspecified
PA95199Medicare PIN