1912087362 NPI number — MIDWEST FAMILY EYE CENTER PA

Table of content: (NPI 1912087362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912087362 NPI number — MIDWEST FAMILY EYE CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST FAMILY EYE CENTER PA
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:
Provider Other Organization Name Type Code:
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:
1912087362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7870 EXCELSIOR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAXTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56425-8427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-828-9545
Provider Business Mailing Address Fax Number:
218-828-1572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7870 EXCELSIOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56425-8427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-828-9545
Provider Business Practice Location Address Fax Number:
218-828-1572
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCALL
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OPTOMETRIST/OWNER
Authorized Official Telephone Number:
218-828-9545

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 54B93MI . This is a "BLUE CROSS BLUE SHIELD-GLASSES" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 05N46MI . This is a "BLUE CROSS BLUE SHIELD, STAPLES" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DC7353 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DD9020 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 05N76MI . This is a "BLUE CROSS BLUE SHIELD, GLASSES, STAPLES" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 46B88MI . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 198523000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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