Basic Information
| Provider Information | |||||||||
| NPI: | 1780980516 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST EYE CONSULTANTS, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIDWEST EYE CONSULTANTS #42 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | WABASH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469920549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2605699550 | ||||||||
| FaxNumber: | 2605699244 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 N IRONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466152518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742893937 | ||||||||
| FaxNumber: | 5742807355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2011 | ||||||||
| LastUpdateDate: | 12/11/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARNER | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES./CEO | ||||||||
| AuthorizedOfficialTelephone: | 2605699550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDWEST EYE CONSULTANTS, P.C. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 56000164A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 100082470V | 05 | IN | MEDICAID |