Basic Information
| Provider Information | |||||||||
| NPI: | 1225179070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELHAM | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 COMMONWEALTH AVE | ||||||||
| Address2: | NEW ENGLAND EYE INSTITUTE | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022151274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172622020 | ||||||||
| FaxNumber: | 6172366323 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 COMMONWEALTH AVE | ||||||||
| Address2: | NEW ENGLAND EYE INSTITUTE | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172622020 | ||||||||
| FaxNumber: | 6172366323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 03/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 4184 | MA | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 0702374 | 05 | MA | MEDICAID | OP2440 | 01 | MA | EYEMED | OTHER |