1457452021 NPI number — MEDICAL CENTER OPHTHALMOLOGY ASSOC PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457452021 NPI number — MEDICAL CENTER OPHTHALMOLOGY ASSOC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL CENTER OPHTHALMOLOGY ASSOC 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:
1457452021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4727 ST ANTOINE ST
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-831-4090
Provider Business Mailing Address Fax Number:
313-831-4089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4727 ST ANTOINE ST
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-831-4090
Provider Business Practice Location Address Fax Number:
313-831-4089
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOODS
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-831-4090

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  DW031072 , 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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