Basic Information
| Provider Information | |||||||||
| NPI: | 1982239828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AEG PENNSYLVANIA PROFESSIONAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 WEXFORD DRIVE | ||||||||
| Address2: | STE 301 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150906923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
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| Address1: | 110 WEXFORD DRIVE | ||||||||
| Address2: | STE 301 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150901509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
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| ProviderEnumerationDate: | 03/11/2020 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHORT | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6184629818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.