Healthcare Provider Details

I. General information

NPI: 1750980850
Provider Name (Legal Business Name): AEG OHIO PROFESSIONAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 STATE RD STE 103
ASHTABULA OH
44004-5957
US

IV. Provider business mailing address

211 E BROADWAY
ALTON IL
62002-6220
US

V. Phone/Fax

Practice location:
  • Phone: 440-997-2020
  • Fax:
Mailing address:
  • Phone: 618-462-9818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MELISSA ALLISON
Title or Position: SR. DIRECTOR MVC
Credential:
Phone: 314-741-8183