1689794596 NPI number — GREAT LAKES EYE ASSOCIATES, PLC

Table of content: (NPI 1689794596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689794596 NPI number — GREAT LAKES EYE ASSOCIATES, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES EYE ASSOCIATES, 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:
ARTHUR J TATGE, D.O.
Provider Other Organization Name Type Code:
5
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:
1689794596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
944 BALDWIN RD
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
LAPEER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48446-3089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-667-6408
Provider Business Mailing Address Fax Number:
810-667-6492

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
944 BALDWIN RD
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
LAPEER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48446-3089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-667-6408
Provider Business Practice Location Address Fax Number:
810-667-6492
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TATGE
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
810-667-6408

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  AT014727 , 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: 1852510715 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P32946F . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4691258 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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