Basic Information
| Provider Information | |||||||||
| NPI: | 1003437823 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES EYE INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2393 SCHUST RD | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486031334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897932820 | ||||||||
| FaxNumber: | 9897551463 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 WOODSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487085468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897932820 | ||||||||
| FaxNumber: | 9897551463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2020 | ||||||||
| LastUpdateDate: | 05/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | HEATH | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9897932820 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1427090976 | 05 | MI | MEDICAID |