Basic Information
| Provider Information | |||||||||
| NPI: | 1922004514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACIK | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 WILLMAR AVE SW | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315000 | ||||||||
| FaxNumber: | 2202315067 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 WILLMAR AVE SW | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315000 | ||||||||
| FaxNumber: | 2202315067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 12/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | MN2973 | MN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 339M8MA | 01 | MN | BCBS | OTHER | 22-02526 | 01 | MN | MEDICA/UNITED HEALTH CARE | OTHER | 222010 | 01 | MN | COLE MANAGED VISION CARE | OTHER | 2237465 | 01 | MN | AMERICA'S PPO | OTHER | 650127300 | 05 | MN | MEDICAID | MN2973 | 01 | MN | EYEMED VISION CARE | OTHER |