MEDICARE: OPHTHALMOLOGY CTR. , LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies		NJ
2	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	55507	OTHER	NJ	US HEALTHCARE
2	0114330000	OTHER	NJ	AMERIHEALTH

General Provider Information

NPI Number	:	1043264195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPHTHALMOLOGY CTR. , LTD.

Provider Business Mailing Address
First Line	:	1637 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-1003
Country	:	US
Telephone Number	:	215-465-7100
Fax Number	:	215-463-3550

Provider Business Practice Location Address
First Line	:	1637 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-1003
Country	:	US
Telephone Number	:	215-465-7100
Fax Number	:	215-463-3550

Authorized Official
Title or Position	:	OFFICE SUPERVISOR
Name	:	MRS. GAIL MUSSOLINE
Credential	:
Telephone Number	:	856-429-2199

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	02/06/2013

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Directions to “OPHTHALMOLOGY CTR. , LTD. ” Practice Location

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