Provider Demographics
NPI:1457380552
Name:PHILADELPHIA VISION CENTER OF MONTGOMERY COUNTY INC
Entity Type:Organization
Organization Name:PHILADELPHIA VISION CENTER OF MONTGOMERY COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOISSELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-885-8500
Mailing Address - Street 1:2401 W CHELTENHAM AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-2946
Mailing Address - Country:US
Mailing Address - Phone:215-885-8500
Mailing Address - Fax:
Practice Address - Street 1:2401 W CHELTENHAM AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-2946
Practice Address - Country:US
Practice Address - Phone:215-885-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOB007398A152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01430122Medicaid
PAU35156Medicare UPIN
PA01430122Medicaid