Basic Information
| Provider Information | |||||||||
| NPI: | 1407803414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED RETINAL CONSULTANTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39650 ORCHARD HILL PL | ||||||||
| Address2: | 200 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483190161 | ||||||||
| FaxNumber: | 2483190170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1179 E PARIS AVE SE | ||||||||
| Address2: | 250 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495463682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422406 | ||||||||
| FaxNumber: | 6169421165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | TRESE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2482882269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 38-146761 | 01 | GRP TAX ID # | OTHER | G00698 | 01 | BCN GRP # | OTHER | 180Q26082 | 01 | BCBS GRP # | OTHER | 791183369 | 01 | MEDICARE RAILROAD GRP # | OTHER |