Provider Demographics
NPI:1801009766
Name:MT HOLLY EYE PHYSICIANS & SURGEONS
Entity Type:Organization
Organization Name:MT HOLLY EYE PHYSICIANS & SURGEONS
Other - Org Name:MT HOLLY OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-267-5577
Mailing Address - Street 1:1613 ROUTE 38
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-2921
Mailing Address - Country:US
Mailing Address - Phone:609-267-5577
Mailing Address - Fax:609-267-5570
Practice Address - Street 1:1613 ROUTE 38
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-2921
Practice Address - Country:US
Practice Address - Phone:609-267-5577
Practice Address - Fax:609-267-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65455332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3099717Medicaid
NJ3099717Medicaid