Provider Demographics
NPI:1811059306
Name:PENINSULA EYE CENTER, P.A
Entity type:Organization
Organization Name:PENINSULA EYE CENTER, P.A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:NOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-749-9290
Mailing Address - Street 1:101 MILFORD ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-6952
Mailing Address - Country:US
Mailing Address - Phone:410-749-9290
Mailing Address - Fax:410-543-9087
Practice Address - Street 1:101 MILFORD ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6952
Practice Address - Country:US
Practice Address - Phone:410-749-9290
Practice Address - Fax:410-543-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1060261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
213769OtherMAMSI
MD57466701OtherCAREFIRST BLUE CROSS
6800028OtherUNITED HEALTHCARE
2353563OtherAETNA HMO
45227OtherCOVENTRY
5575535OtherAETNA NON-HMO
MD778441400Medicaid
MDPH5OtherCAREFIRST BLUE CHOICE
DE0000464928Medicaid
45227OtherCOVENTRY
DE0000464928Medicaid