1356698534 NPI number — MID MICHIGAN FAMILY EYE CARE PLLC

Table of content: (NPI 1356698534)

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".




Copyright © 2007-2024 www.npivalidator.com