Provider Demographics
NPI:1720255508
Name:RUSSIN EYE LLC
Entity Type:Organization
Organization Name:RUSSIN EYE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUSSIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:610-617-4177
Mailing Address - Street 1:301 CITY AVENUE
Mailing Address - Street 2:SUITE 335
Mailing Address - City:BALA CYNWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19004
Mailing Address - Country:US
Mailing Address - Phone:610-617-4177
Mailing Address - Fax:610-617-4170
Practice Address - Street 1:301 CITY AVENUE
Practice Address - Street 2:SUITE 335
Practice Address - City:BALA CYNWOOD
Practice Address - State:PA
Practice Address - Zip Code:19004
Practice Address - Country:US
Practice Address - Phone:610-617-4177
Practice Address - Fax:610-617-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009908L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001697374Medicaid
PA001697374Medicaid