Provider Demographics
NPI:1750347662
Name:VITREO-RETINAL CONSULTANTS, INC.
Entity type:Organization
Organization Name:VITREO-RETINAL CONSULTANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GERSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-494-1116
Mailing Address - Street 1:4676 DOUGLAS CIR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3619
Mailing Address - Country:US
Mailing Address - Phone:330-494-1116
Mailing Address - Fax:330-494-0276
Practice Address - Street 1:4676 DOUGLAS CIR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3619
Practice Address - Country:US
Practice Address - Phone:330-494-1116
Practice Address - Fax:330-494-0276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015118480004Medicaid
OH0693576Medicaid
WV6300115000Medicaid
OH9925686Medicare PIN
OH9925681Medicare PIN
OH9925685Medicare PIN
WV6300115000Medicaid
PACG3259Medicare PIN
OHCM3882Medicare PIN
PA901665Medicare PIN
OH9925683Medicare PIN