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General NPI Number Information
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NPI Number | 1154325686
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Entity Type | Organization
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Legal Business Name | BERKSHIRE EYE SURGERY CENTER LP
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Dates
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Enumeration Date | 06/13/2005
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Last Update Date | 11/20/2009
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Provider Practice Location Address
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Address Line | 2220 RIDGEWOOD RD
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City | WYOMISSING
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State | PA
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Zip | 19610-1167
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Country | US
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Telephone | 610-736-0144
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Fax | 610-736-0926
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Provider Business Mailing Address
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Address Line | 2220 RIDGEWOOD RD
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City | WYOMISSING
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State | PA
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Zip | 19610-1167
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Country | US
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Telephone | 610-736-0144
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Fax | 610-736-0926
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. DOMENIC C IZZO JR.
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Credential | M.D.
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Telephone | 610-736-0144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 15291501
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License Number State | PA
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