MEDICARE: BROOKHAVEN FAMILY EYE CARE CENTER

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	332H00000X	Eyewear Supplier	OEG001547	PA
2	152W00000X	Optometrist	OEG001547	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CM9120	OTHER	PA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2628516	OTHER	PA	AETNA GROUP HMO
3	5498366	OTHER	PA	AETNA UNIVERSAL GROUP
4	2115330000	OTHER	PA	INDEPENDENCE BLUE CROSS
5	001429488	OTHER	PA	HIGHMARK

General Provider Information

NPI Number	:	1760490494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKHAVEN FAMILY EYE CARE CENTER

Provider Business Mailing Address
First Line	:	4106 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2314
Country	:	US
Telephone Number	:	610-872-8989
Fax Number	:	610-872-5220

Provider Business Practice Location Address
First Line	:	4106 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2314
Country	:	US
Telephone Number	:	610-872-8989
Fax Number	:	610-872-5220

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICAELA L SMALL
Credential	:	OD
Telephone Number	:	610-872-8989

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	05/14/2024

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Directions to “BROOKHAVEN FAMILY EYE CARE CENTER ” Practice Location

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