Provider Demographics
NPI:1588892244
Name:VITREO-RETINAL ASSOCIATES PC
Entity type:Organization
Organization Name:VITREO-RETINAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHAMPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-752-1155
Mailing Address - Street 1:67 BELMONT ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2657
Mailing Address - Country:US
Mailing Address - Phone:508-752-1155
Mailing Address - Fax:508-752-4862
Practice Address - Street 1:67 BELMONT ST STE 302
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2608
Practice Address - Country:US
Practice Address - Phone:865-531-0176
Practice Address - Fax:508-752-4862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0013345OtherMEDICARE PTAN
MAM19742OtherBC/BS GROUP NUMBER
MA110068662AMedicaid
MA110068662AMedicaid
MA0013345Medicare PIN