Provider Demographics
NPI:1902152762
Name:MID MICHIGAN FAMILY EYE CARE PLLC
Entity Type:Organization
Organization Name:MID MICHIGAN FAMILY EYE CARE PLLC
Other - Org Name:MID MICHIGAN EYE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HALES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-386-2020
Mailing Address - Street 1:1520 N MCEWAN ST STE B
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1196
Mailing Address - Country:US
Mailing Address - Phone:989-386-2020
Mailing Address - Fax:989-386-7308
Practice Address - Street 1:1520 N MCEWAN ST # B
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1196
Practice Address - Country:US
Practice Address - Phone:989-386-2020
Practice Address - Fax:989-386-7308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A80041OtherBLUECROSS BLUESHIELD
MI1902152762Medicaid
MIMI6157Medicare PIN
MI6745560002Medicare NSC
MI0A80041OtherBLUECROSS BLUESHIELD
MIMI6157Medicare Oscar/Certification