Basic Information
| Provider Information | |||||||||
| NPI: | 1477172138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EERNISSE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 FARM COLONY DR | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163655203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164846700 | ||||||||
| FaxNumber: | 7164870166 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 FARM COLONY DR | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163655203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164846700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2020 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TUV009265 | NY | N | Eye and Vision Services Providers | Optometrist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | OEG003709 | PA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 103797012 | 05 | PA | MEDICAID | 06352987 | 05 | NY | MEDICAID |