Provider Demographics
NPI:1871550996
Name:VITREO RETINAL CONSULTANTS OF THE PALM BEACHES PA
Entity type:Organization
Organization Name:VITREO RETINAL CONSULTANTS OF THE PALM BEACHES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:MR
Authorized Official - First Name:SALOMON
Authorized Official - Middle Name:EMILIO
Authorized Official - Last Name:MELGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-687-0007
Mailing Address - Street 1:2521 METROCENTRE BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407
Mailing Address - Country:US
Mailing Address - Phone:561-687-0007
Mailing Address - Fax:561-688-0431
Practice Address - Street 1:2521 METROCENTRE BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407
Practice Address - Country:US
Practice Address - Phone:561-687-0007
Practice Address - Fax:561-688-0431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56172OtherBLUE CROSS BLUE SHIELD
FL064710100Medicaid
FL56172OtherBLUE CROSS BLUE SHIELD
A56931Medicare UPIN