Provider Demographics
NPI:1730286097
Name:PLYMOUTH MEETING AMBULATORY SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:PLYMOUTH MEETING AMBULATORY SURGICAL CENTER LLC
Other - Org Name:WILLS EYE SURGERY CENTER OF PLYMOUTH MEETING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR DIRECTOR OF NURSING
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:P
Authorized Official - Last Name:KRZESINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:610-834-9700
Mailing Address - Street 1:625 W RIDGE PIKE
Mailing Address - Street 2:BUILDING B
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-1180
Mailing Address - Country:US
Mailing Address - Phone:610-834-9700
Mailing Address - Fax:610-834-9992
Practice Address - Street 1:625 W RIDGE PIKE
Practice Address - Street 2:BUILDING B
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-1180
Practice Address - Country:US
Practice Address - Phone:610-834-9700
Practice Address - Fax:610-834-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA07451500261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001639951003Medicaid
PA0001379000OtherBLUE CROSS PROVIDER NUMBE
PA001639951003Medicaid