Provider Demographics
NPI:1104238088
Name:AEG PENNSYLVANIA PROFESSIONAL, INC
Entity type:Organization
Organization Name:AEG PENNSYLVANIA PROFESSIONAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-462-9818
Mailing Address - Street 1:111 E 4TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6206
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:314-741-4947
Practice Address - Street 1:411 BEAVER ST
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143
Practice Address - Country:US
Practice Address - Phone:412-422-5300
Practice Address - Fax:314-741-4947
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AEG PENNSYLVANIA PROFESSIONAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-27
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
PA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty