1164552972 NPI number — GREAT LAKES EYE CONSULTANTS PLC

Table of content: (NPI 1164552972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164552972 NPI number — GREAT LAKES EYE CONSULTANTS PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES EYE CONSULTANTS PLC
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:
1164552972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ACME
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49610-0308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-947-1690
Provider Business Mailing Address Fax Number:
231-947-1692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
872 MUNSON AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-947-1690
Provider Business Practice Location Address Fax Number:
231-947-1692
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FEDOR
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
231-947-1690

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  4301061885 , 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: 104609642 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104609651 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104609660 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104609633 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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