Provider Demographics
NPI:1811231814
Name:MARYLAND VISION INSTITUTE, LLC
Entity Type:Organization
Organization Name:MARYLAND VISION INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AUGUSTUS
Authorized Official - Middle Name:G
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-723-0673
Mailing Address - Street 1:220 CHAMPION DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6558
Mailing Address - Country:US
Mailing Address - Phone:301-791-0888
Mailing Address - Fax:301-791-3611
Practice Address - Street 1:220 CHAMPION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6558
Practice Address - Country:US
Practice Address - Phone:301-791-0888
Practice Address - Fax:301-791-3611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD263393Medicare PIN