Basic Information
Provider Information | |||||||||
NPI: | 1851800858 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDWEST EYE CONSULTANTS P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MIDWEST EYE CONSULTANTS #52 | ||||||||
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: | 2605690760 | ||||||||
Practice Location | |||||||||
Address1: | 710 S 13TH ST | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | IN | ||||||||
PostalCode: | 467331802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2607244318 | ||||||||
FaxNumber: | 2607249776 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2017 | ||||||||
LastUpdateDate: | 01/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARNER | ||||||||
AuthorizedOfficialFirstName: | GREGORY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2605699550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MIDWEST EYE CONSULTANTS P.C. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 300009717 | 05 | IN |   | MEDICAID |