Basic Information
| Provider Information | |||||||||
| NPI: | 1215014832 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGANY OPTICAL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALLEGANY OPTICAL NATIONAL OPTOMETRY ALLEGANY OPTOMETRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 19336 LEITERSBURG PIKE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015820675 | ||||||||
| FaxNumber: | 3015823293 | ||||||||
| Practice Location | |||||||||
| Address1: | 12916 CONAMAR DR | ||||||||
| Address2: | STE. 104 | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217422760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017334944 | ||||||||
| FaxNumber: | 3017335220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/21/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLEMING | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | MILLS | ||||||||
| AuthorizedOfficialTitleorPosition: | OD / MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3042679911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 21237249 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | LM13 | 01 | CAREFIRST | OTHER | CJ5438 | 01 | MD | RAILROAD MEDICARE | OTHER |