1780746081 NPI number — MICHIGAN VISION INSTITUTE PLLC

Table of content: (NPI 1780746081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780746081 NPI number — MICHIGAN VISION INSTITUTE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN VISION INSTITUTE 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:
MICHIGAN VISION INSTITUTE
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:
1780746081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 GATEWAY CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507-3930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-720-9111
Provider Business Mailing Address Fax Number:
810-720-9119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 GATEWAY CTR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48507-3930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-720-9111
Provider Business Practice Location Address Fax Number:
810-720-9119
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STACK
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
810-720-9111

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  4301065179 , 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: 0995895 . This is a "HEALTHPLUS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: G08694 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1015959 . This is a "MCLAREN HEALTH ADV" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4774225 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5100110 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1802511821 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 000000013286 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1802511821 . This is a "BLUECARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C6993 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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