Provider Demographics
NPI:1558305219
Name:EYE SURGICAL MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:EYE SURGICAL MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-342-8118
Mailing Address - Street 1:8118 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152
Mailing Address - Country:US
Mailing Address - Phone:215-342-8118
Mailing Address - Fax:215-725-4999
Practice Address - Street 1:8118 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-2803
Practice Address - Country:US
Practice Address - Phone:215-342-8118
Practice Address - Fax:215-725-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE005574152W00000X
PA207W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA890541OtherHIGHMARK BLUE SHIELD
PA00531400000OtherDENNIS J KHOURY MD
PA0010888550007Medicaid
PA114458OtherHIGHMARK BLUE SHIELD
PA57346OtherAETNA
PACF4471OtherRAILROAD MEDICARE
PA0053194000OtherM SHAYEGAN MD
PA2740362000OtherIBC
PA0053171000OtherKEYSTONE
PA180010359OtherRAILROAD MEDICARE
PA=========OtherEYE SURGICAL MEDICAL ASSO
PA114458Medicare PIN
PA102898FKSMedicare PIN
PA57346OtherAETNA
PA=========OtherEYE SURGICAL MEDICAL ASSO
PA180010359OtherRAILROAD MEDICARE
PA2740362000OtherIBC
PA054328FKSMedicare PIN
PA064032FKSMedicare PIN
PAB34689Medicare UPIN
PA0010888550007Medicaid