MEDICARE: AEG PENNSYLVANIA PROFESSIONAL, INC

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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1639906563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AEG PENNSYLVANIA PROFESSIONAL, INC

Provider Business Mailing Address
First Line	:	111 E 4TH ST STE 440
Second Line	:
City	:	ALTON
State	:	IL
Zip	:	62002-6206
Country	:	US
Telephone Number	:	314-741-8183
Fax Number	:

Provider Business Practice Location Address
First Line	:	20808 ROUTE 19
Second Line	:
City	:	CRANBERRY TOWNSHIP
State	:	PA
Zip	:	16066-6022
Country	:	US
Telephone Number	:	724-591-8212
Fax Number	:

Authorized Official
Title or Position	:	SR. DIRECTOR OF RCM
Name	:	MELISSA ALLISON
Credential	:
Telephone Number	:	314-741-8183

Provider Enumeration Date	:	09/16/2024
Last Update Date	:	09/16/2024

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