MEDICARE: PREMIERVISION LASER CENTER, INC.

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	MD069007L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	187975	OTHER		MEDICARE-PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699833855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIERVISION LASER CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 539
Second Line	:
City	:	WILLOW GROVE
State	:	PA
Zip	:	19090-0539
Country	:	US
Telephone Number	:	215-657-5044
Fax Number	:	215-657-5046

Provider Business Practice Location Address
First Line	:	3212 W CHELTENHAM AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-1003
Country	:	US
Telephone Number	:	215-657-5044
Fax Number	:	215-657-5046

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CORDELIA NKOLIKA UDDOH
Credential	:	MD
Telephone Number	:	215-657-5044

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/30/2020

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Directions to “PREMIERVISION LASER CENTER, INC. ” Practice Location

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