1053650473 NPI number — CLINTON OPHTHALMOLOGY, PC

Table of content: (NPI 1053650473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053650473 NPI number — CLINTON OPHTHALMOLOGY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINTON OPHTHALMOLOGY, PC
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:
1053650473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 E STURGIS ST
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
SAINT JOHNS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48879-2068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-224-1452
Provider Business Mailing Address Fax Number:
989-224-1453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E STURGIS ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SAINT JOHNS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48879-2068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-224-1452
Provider Business Practice Location Address Fax Number:
989-224-1453
Provider Enumeration Date:
02/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
BRANDY
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
989-224-1452

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  5101016172 , 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)





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