Basic Information
| Provider Information | |||||||||
| NPI: | 1770772295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEHIGH VALLEY PHYSICIAN GROUP | ||||||||
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| OtherOrganizationName: | LVPG OPTHALMOLOGY - 17TH STREET | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78331 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191783311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 N 17TH ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181045034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109693070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | DEMOPOULOS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VP | ||||||||
| AuthorizedOfficialTelephone: | 4848623333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEHIGH VALLEY PHYSICIAN GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.