1356698534 NPI number — MID MICHIGAN FAMILY EYE CARE PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356698534 NPI number — MID MICHIGAN FAMILY EYE CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID MICHIGAN FAMILY EYE CARE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MID MICHIGAN EYE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356698534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48612-0505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-435-2020
Provider Business Mailing Address Fax Number:
989-435-2554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
334 N ROSS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48612-8165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-435-2020
Provider Business Practice Location Address Fax Number:
989-435-2554
Provider Enumeration Date:
08/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HALES
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
989-435-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901004640 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1356698534 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0A80041 . This is a "BLUECROSS BLUESHIED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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