Provider Demographics
NPI:1639469000
Name:CORNERBROOK PLAZA EYE CARE P A
Entity Type:Organization
Organization Name:CORNERBROOK PLAZA EYE CARE P A
Other - Org Name:PORTLAND EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:EBBERT
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-253-5333
Mailing Address - Street 1:1040 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102
Mailing Address - Country:US
Mailing Address - Phone:207-253-5333
Mailing Address - Fax:
Practice Address - Street 1:1040 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-253-5333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMEOPT860152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9591Medicare UPIN