Basic Information
| Provider Information | |||||||||
| NPI: | 1710963152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRS. BAALS AND WIEGAND FAMILY EYE CARE P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 240 HOOSIER DR | ||||||||
| Address2: | |||||||||
| City: | ANGOLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467039314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606683937 | ||||||||
| FaxNumber: | 2606683794 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 HOOSIER DR | ||||||||
| Address2: | |||||||||
| City: | ANGOLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467039314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606683937 | ||||||||
| FaxNumber: | 2606683794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAALS | ||||||||
| AuthorizedOfficialFirstName: | GREY | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2606683937 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 56000221A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000104867 | 01 | IN | ANTHEM GROUP NUMBER | OTHER |