1871857417 NPI number — MIDWEST EYE CONSULTANTS, P.C.

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 1871857417 NPI number — MIDWEST EYE CONSULTANTS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST EYE CONSULTANTS, P.C.
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:
MIDWEST EYE CONSULTANTS - ANGOLA
Provider Other Organization Name Type Code:
3
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:
1871857417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WABASH
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46992-0549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-569-9550
Provider Business Mailing Address Fax Number:
260-569-0760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 HOOSIER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGOLA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46703-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-668-3937
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GARNER
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRES/CEO
Authorized Official Telephone Number:
260-569-9550

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  56000164A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100082470Y , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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