Basic Information
| Provider Information | |||||||||
| NPI: | 1487834982 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGANY OPTICAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLEGANY OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17301 VALLEY MALL RD | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217406966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015821771 | ||||||||
| FaxNumber: | 3015824681 | ||||||||
| Practice Location | |||||||||
| Address1: | 17301 VALLEY MALL RD | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217406966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015821771 | ||||||||
| FaxNumber: | 3015824681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLEMING | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | O.D. / MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3042679911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 09135972 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0550035-00,01 | 05 | MD | MEDICAID | CJ5438 | 01 | MD | RAILROAD MEDICARE | OTHER | LM13AL | 01 | MD | CAREFIRST BC / BS | OTHER |