=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063526713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL RETINA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 06/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6115 FALLS RD SUITE 300
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-377-9004
-----------------------------------------------------
Fax | 410-377-8221
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6115 FALLS RD SUITE 300
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-377-9004
-----------------------------------------------------
Fax | 410-377-8221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RANDALL V WONG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 410-377-9004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | D0041207
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------