1619038312 NPI number — BIRMINGHAM VISION CARE

Table of content: (NPI 1619038312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619038312 NPI number — BIRMINGHAM VISION CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIRMINGHAM VISION CARE
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:
1619038312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4114 W MAPLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48301-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-539-4800
Provider Business Mailing Address Fax Number:
248-539-4894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4114 W MAPLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-539-4800
Provider Business Practice Location Address Fax Number:
248-539-4894
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PELTON
Authorized Official First Name:
HARRIET
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-539-4800

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 900F378080 . This is a "BCBS MI" identifier . This identifiers is of the category "OTHER".




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