Provider Demographics
NPI:1952796187
Name:PROFESSIONAL VISION OF ELLICOTT CITY, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL VISION OF ELLICOTT CITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-465-6166
Mailing Address - Street 1:8450 BALTIMORE NATIONAL PIKE STE 155
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3909
Mailing Address - Country:US
Mailing Address - Phone:410-465-6166
Mailing Address - Fax:
Practice Address - Street 1:8450 BALTIMORE NATIONAL PIKE STE 155
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3909
Practice Address - Country:US
Practice Address - Phone:410-465-6166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty