MEDICARE: PHILADELPHIA VISION ASSOCIATES GROUP PRACTICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1578664959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILADELPHIA VISION ASSOCIATES GROUP PRACTICE LLC

Provider Business Mailing Address
First Line	:	1516 LOCUST ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-4401
Country	:	US
Telephone Number	:	215-546-0493
Fax Number	:	610-337-2133

Provider Business Practice Location Address
First Line	:	1516 LOCUST ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102
Country	:	US
Telephone Number	:	215-546-0493
Fax Number	:	610-337-2133

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	KIM MILLER
Credential	:
Telephone Number	:	610-491-2127

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	06/25/2018

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