1346424272 NPI number — GREAT LAKES EYE INSTITUTE

Table of content: SAMANTHA WATSON (NPI 1114686672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346424272 NPI number — GREAT LAKES EYE INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES EYE INSTITUTE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346424272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2393 SCHUST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48603-1334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-793-2820
Provider Business Mailing Address Fax Number:
989-793-9132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
623 W WARWICK DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
ALMA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48801-1177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-463-1126
Provider Business Practice Location Address Fax Number:
989-463-6013
Provider Enumeration Date:
12/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHOKOOHI
Authorized Official First Name:
FARHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
989-793-2820

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 4301040619 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CA3610 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0467800006 . This is a "ADMINASTAR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 180G300890 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 180G300890 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 180G310710 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0G36036 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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