Provider Demographics
NPI:1659783132
Name:SPECIALIZED EYE CARE OF BAY RIDGE, LLC
Entity Type:Organization
Organization Name:SPECIALIZED EYE CARE OF BAY RIDGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-848-5484
Mailing Address - Street 1:8723 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-5103
Mailing Address - Country:US
Mailing Address - Phone:718-491-2020
Mailing Address - Fax:
Practice Address - Street 1:8723 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-5103
Practice Address - Country:US
Practice Address - Phone:718-491-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009057332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7183350001OtherMEDICARE PTAN