Basic Information
| Provider Information | |||||||||
| NPI: | 1326087156 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RETINA VITREAUS CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASSOCIATED RETINA CONSULTANTS LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 GALLOPING HILL RD | ||||||||
| Address2: | |||||||||
| City: | KENILWORTH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070331303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9084888333 | ||||||||
| FaxNumber: | 9084588339 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 GALLOPING HILL RD | ||||||||
| Address2: | |||||||||
| City: | KENILWORTH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070331303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9084888333 | ||||||||
| FaxNumber: | 9084588339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LUDWIG | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7325681246 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | FACMPE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.