Provider Demographics
NPI:1598068504
Name:PHILADELPHIA EYECARE PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:PHILADELPHIA EYECARE PROFESSIONALS, LLC
Other - Org Name:PHILADELPHIA EYECARE PROFESSIONALS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURAKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:215-530-3112
Mailing Address - Street 1:10 WEATHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19087-2724
Mailing Address - Country:US
Mailing Address - Phone:215-530-3112
Mailing Address - Fax:215-755-6561
Practice Address - Street 1:1601 S COLUMBUS BLVD
Practice Address - Street 2:VISION CENTER INSIDE WALMART
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-1400
Practice Address - Country:US
Practice Address - Phone:215-389-5814
Practice Address - Fax:215-755-6561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015391140003Medicaid
PABU202875Medicare PIN