Healthcare Provider Details

I. General information

NPI: 1518575778
Provider Name (Legal Business Name): EYE SURGERY OF THE MAIN LINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E CITY AVENUE TWO BALA PLAZA
BALA CYNWYD PA
19004-1501
US

IV. Provider business mailing address

333 E CITY AVE TWO BALA PLAZA
BALA CYNWYD PA
19004-1501
US

V. Phone/Fax

Practice location:
  • Phone: 610-668-2777
  • Fax:
Mailing address:
  • Phone: 610-668-2847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANITA NEVYAS-WALLACE
Title or Position: MEMBER
Credential: MD
Phone: 610-668-2847