Healthcare Provider Details

I. General information

NPI: 1821874439
Provider Name (Legal Business Name): AEG PENNSYLVANIA PROFESSIONAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 E MAIN ST
NEW HOLLAND PA
17557-1404
US

IV. Provider business mailing address

111 E 4TH ST STE 440
ALTON IL
62002-6206
US

V. Phone/Fax

Practice location:
  • Phone: 717-354-2251
  • Fax: 314-741-4947
Mailing address:
  • Phone: 618-462-9818
  • Fax: 314-741-4947

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 RCM/MVC
Credential:
Phone: 618-462-9818