Basic Information
Provider Information | |||||||||
NPI: | 1154325686 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BERKSHIRE EYE SURGERY CENTER LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2220 RIDGEWOOD RD | ||||||||
Address2: |   | ||||||||
City: | WYOMISSING | ||||||||
State: | PA | ||||||||
PostalCode: | 196101167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6107360144 | ||||||||
FaxNumber: | 6107360926 | ||||||||
Practice Location | |||||||||
Address1: | 2220 RIDGEWOOD RD | ||||||||
Address2: |   | ||||||||
City: | WYOMISSING | ||||||||
State: | PA | ||||||||
PostalCode: | 196101167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6107360144 | ||||||||
FaxNumber: | 6107360926 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2005 | ||||||||
LastUpdateDate: | 11/20/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IZZO | ||||||||
AuthorizedOfficialFirstName: | DOMENIC | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6107360144 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 15291501 | PA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.