Basic Information
| Provider Information | |||||||||
| NPI: | 1962574673 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MPG LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHENANDOAH EYE CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 N AUGUSTA ST | ||||||||
| Address2: | |||||||||
| City: | STAUNTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408850006 | ||||||||
| FaxNumber: | 5408855276 | ||||||||
| Practice Location | |||||||||
| Address1: | 1412 N AUGUSTA ST | ||||||||
| Address2: | |||||||||
| City: | STAUNTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408850006 | ||||||||
| FaxNumber: | 5408855276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOWEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5408850006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618000690 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.