Basic Information
| Provider Information | |||||||||
| NPI: | 1346424272 | ||||||||
| 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: | 9897939132 | ||||||||
| Practice Location | |||||||||
| Address1: | 623 W WARWICK DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488011177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894631126 | ||||||||
| FaxNumber: | 9894636013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 01/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | SHOKOOHI | ||||||||
| AuthorizedOfficialFirstName: | FARHAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MD | ||||||||
| AuthorizedOfficialTelephone: | 9897932820 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | 4301040619 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | CA3610 | 01 | RAILROAD MEDICARE | OTHER | 0467800006 | 01 | MI | ADMINASTAR | OTHER | 180G300890 | 01 | MI | BLUE CARE NETWORK | OTHER | 180G300890 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 180G310710 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 0G36036 | 01 | MEDICARE | OTHER |