Provider Demographics
NPI:1609848472
Name:PENNSYLVANIA EYE & EAR SURGERY
Entity Type:Organization
Organization Name:PENNSYLVANIA EYE & EAR SURGERY
Other - Org Name:PA EYE & EAR SURGERY CENTER, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:610-378-1348
Mailing Address - Street 1:1 GRANITE POINT DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1986
Mailing Address - Country:US
Mailing Address - Phone:610-685-9204
Mailing Address - Fax:610-685-5308
Practice Address - Street 1:1 GRANITE POINT DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1986
Practice Address - Country:US
Practice Address - Phone:610-685-9204
Practice Address - Fax:610-685-5308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012118620001Medicaid
PA071325Medicare ID - Type Unspecified