Basic Information
| Provider Information | |||||||||
| NPI: | 1871857417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST EYE CONSULTANTS, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIDWEST EYE CONSULTANTS - ANGOLA | ||||||||
| 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: | 240 HOOSIER DR | ||||||||
| Address2: | |||||||||
| City: | ANGOLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467039314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606683937 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2012 | ||||||||
| LastUpdateDate: | 11/20/2012 | ||||||||
| 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: | 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 | 100082470Y | 05 | IN | MEDICAID |