MEDICARE: EYE CENTER OF ELIZABETH LLC

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	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1578072930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE CENTER OF ELIZABETH LLC

Provider Business Mailing Address
First Line	:	219 S BROAD ST
Second Line	:
City	:	ELIZABETH
State	:	NJ
Zip	:	07202-3453
Country	:	US
Telephone Number	:	908-355-1237
Fax Number	:

Provider Business Practice Location Address
First Line	:	219 S BROAD ST
Second Line	:
City	:	ELIZABETH
State	:	NJ
Zip	:	07202-3453
Country	:	US
Telephone Number	:	908-355-1237
Fax Number	:

Authorized Official
Title or Position	:	PRINCIPAL
Name	:	DR. ALESSANDRA BERTOLUCCI CUPPARI
Credential	:	MD
Telephone Number	:	908-202-7324

Provider Enumeration Date	:	09/28/2017
Last Update Date	:	09/28/2017

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