Provider Demographics
NPI:1477801876
Name:BRIERDALE OPTOMETRY PA
Entity type:Organization
Organization Name:BRIERDALE OPTOMETRY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:H
Authorized Official - Last Name:SAID
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-881-0900
Mailing Address - Street 1:3214 CHARLES B ROOT WYND
Mailing Address - Street 2:SUITE 155
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5440
Mailing Address - Country:US
Mailing Address - Phone:919-881-0900
Mailing Address - Fax:919-341-5273
Practice Address - Street 1:10371 MONCREIFFE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7817
Practice Address - Country:US
Practice Address - Phone:919-341-4435
Practice Address - Fax:919-341-5273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC026Y1OtherBLUE CROSS BLUE SHIELD
NC2484326Medicare PIN
NCC476Medicare PIN