Provider Demographics
NPI:1245203405
Name:KINGSTON OPHTHALMOLOGY ASC LLC
Entity type:Organization
Organization Name:KINGSTON OPHTHALMOLOGY ASC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:601 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3701
Mailing Address - Country:US
Mailing Address - Phone:570-288-7405
Mailing Address - Fax:570-714-0419
Practice Address - Street 1:601 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3701
Practice Address - Country:US
Practice Address - Phone:570-288-7405
Practice Address - Fax:570-714-0419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA94941500261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA490003620OtherRAILROAD MEDICARE
PA001696312001OtherMEDICAL ASSISTANCE
PA01835908Medicaid
PA804568OtherFIRST PRIORITY HEALTH
PA999035OtherBLUE CROSS
PA=========001OtherTRICARE
PA804568OtherFIRST PRIORITY HEALTH
PA300858Medicare PIN