Provider Demographics
NPI:1912021759
Name:SIEGMUND EYE CARE PA
Entity Type:Organization
Organization Name:SIEGMUND EYE CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEGMUND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-796-1155
Mailing Address - Street 1:4278 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5603
Mailing Address - Country:US
Mailing Address - Phone:843-796-1155
Mailing Address - Fax:843-796-1153
Practice Address - Street 1:4278 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-5603
Practice Address - Country:US
Practice Address - Phone:843-796-1155
Practice Address - Fax:843-796-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1389152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1073675690OtherINDIVIDUAL NPI - JASON
SC1528120144OtherINDIVIDUAL NPI - KELLE