1518029909 NPI number — CEDAR RUN EYE CENTER, PLLC

Table of content: (NPI 1518029909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518029909 NPI number — CEDAR RUN EYE CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR RUN EYE CENTER, 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:
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:
1518029909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3830 W FRONT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49684-8153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-929-3888
Provider Business Mailing Address Fax Number:
231-929-4365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3830 W FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684-8153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-929-3888
Provider Business Practice Location Address Fax Number:
231-929-4365
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANLEY
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
231-929-3888

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901003094 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 4901003086 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 4901004107 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 4301048021 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 4301048021 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 900001413 . This is a "PRIORITY - CREC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900B86347001 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 180B86357 . This is a "BCBS TBH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900B86347003 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1134113517 . This is a "RAILROAD MEDICARE/CIZEK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900B86347 . This is a "BCBS OPTOM GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 943166469 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 943166487 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CN1586 . This is a "RAILROAD MEDICARE/CREC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 943166496 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1020070001 . This is a "DMERC REGION B" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 102022 . This is a "PREFERRED CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1144214180 . This is a "RAILROAD MEDICARE/HANLEY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CG1308 . This is a "RAILROAD MEDICARE/TSC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103164508 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1497736102 . This is a "RAILROAD MEDICARE/HUMMEL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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