Healthcare Provider Details

I. General information

NPI: 1154325686
Provider Name (Legal Business Name): BERKSHIRE EYE SURGERY CENTER LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 RIDGEWOOD RD
WYOMISSING PA
19610-1167
US

IV. Provider business mailing address

2220 RIDGEWOOD RD
WYOMISSING PA
19610-1167
US

V. Phone/Fax

Practice location:
  • Phone: 610-736-0144
  • Fax: 610-736-0926
Mailing address:
  • Phone: 610-736-0144
  • Fax: 610-736-0926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number15291501
License Number StatePA

VIII. Authorized Official

Name: DR. DOMENIC C IZZO JR.
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 610-736-0144