Provider Demographics
NPI:1861472870
Name:MIDATLANTIC OPHTHALMOLOGY GROUP PA
Entity Type:Organization
Organization Name:MIDATLANTIC OPHTHALMOLOGY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CMIELEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-741-0858
Mailing Address - Street 1:70 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1851
Mailing Address - Country:US
Mailing Address - Phone:732-741-0858
Mailing Address - Fax:732-219-0180
Practice Address - Street 1:70 E FRONT ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1851
Practice Address - Country:US
Practice Address - Phone:732-741-0858
Practice Address - Fax:732-219-0180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4555708Medicaid
NJ155722Medicare PIN
NJ1981050001Medicare NSC