Provider Demographics
NPI:1750456745
Name:ALBEMARLE PEDIATRIC OPHTHALMOLOGY & STRABISMUS PC
Entity Type:Organization
Organization Name:ALBEMARLE PEDIATRIC OPHTHALMOLOGY & STRABISMUS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GALE
Authorized Official - Middle Name:KINNIER
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-295-5193
Mailing Address - Street 1:1101 EAST JEFFERSON STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5353
Mailing Address - Country:US
Mailing Address - Phone:434-295-5193
Mailing Address - Fax:434-977-0714
Practice Address - Street 1:1101 EAST JEFFERSON STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5353
Practice Address - Country:US
Practice Address - Phone:434-295-5193
Practice Address - Fax:434-977-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239819207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA400262000OtherSOUTHERN HEALTH
VA003205OtherANTHEM BCBS
VA006370551Medicaid
1972510113OtherINDIVIDUAL NPI #
VA010299349Medicaid
1477555399OtherINDIVIDUAL NPI #
VA435561OtherSOUTHERN HEALTH
B08794Medicare UPIN
VA006370551Medicaid
VA010299349Medicaid