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General NPI Number Information
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NPI Number | 1720255508
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Entity Type | Organization
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Legal Business Name | RUSSIN EYE LLC
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Dates
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Enumeration Date | 05/12/2008
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Last Update Date | 10/01/2008
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Provider Practice Location Address
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Address Line | 301 CITY AVENUE SUITE 335
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City | BALA CYNWOOD
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State | PA
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Zip | 19004
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Country | US
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Telephone | 610-617-4177
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Fax | 610-617-4170
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Provider Business Mailing Address
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Address Line | 301 CITY AVENUE SUITE 335
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City | BALA CYNWOOD
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State | PA
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Zip | 19004
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Country | US
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Telephone | 610-617-4177
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Fax | 610-617-4170
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Authorized Official
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Title or Position | OWNER
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Name | SIMON R RUSSIN
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Credential | DO
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Telephone | 610-617-4177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | OS009908L
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License Number State | PA
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