Basic Information
Provider Information | |||||||||
NPI: | 1558592170 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDWEST EYE CONSULTANTS P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MIDWEST EYE CONSULTANTS #38 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 549 | ||||||||
Address2: |   | ||||||||
City: | WABASH | ||||||||
State: | IN | ||||||||
PostalCode: | 469920549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2605699550 | ||||||||
FaxNumber: | 2605699244 | ||||||||
Practice Location | |||||||||
Address1: | 17615 STATE ROAD 23 | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466351718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742347600 | ||||||||
FaxNumber: | 5742348408 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2009 | ||||||||
LastUpdateDate: | 10/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARNER | ||||||||
AuthorizedOfficialFirstName: | GREGORY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRES./CEO | ||||||||
AuthorizedOfficialTelephone: | 2605699550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MIDWEST EYE CONSULTANTS, P.C. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5600164A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 100082470S | 05 | IN |   | MEDICAID | CD2507 | 01 | IN | RAILROAD MEDICARE | OTHER |