Basic Information
| Provider Information | |||||||||
| NPI: | 1427090976 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 2393 SCHUST RD | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486031334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897932820 | ||||||||
| FaxNumber: | 9897939132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | SHOKOOHI | ||||||||
| AuthorizedOfficialFirstName: | FARHAD | ||||||||
| AuthorizedOfficialMiddleName: | KAYVAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9897932820 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 43010040619 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 4301102705 | MI | Y | 193200000X MULTI-SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | 180G300890 | 01 | MI | FEDERAL EMPLOYEES PROGRAM BLUE CROSS | OTHER | 180G300890 | 01 | MI | BLUE CARE NETWORK | OTHER | 180G300890 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 0G36036 | 01 | MEDICARE | OTHER | CA3610 | 01 | MI | RR MEDICARE | OTHER |