Provider Demographics
NPI:1063680791
Name:GREAT LAKES EYE INSTITUTE
Entity Type:Organization
Organization Name:GREAT LAKES EYE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHOKOOHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-793-2820
Mailing Address - Street 1:2393 SCHUST RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1334
Mailing Address - Country:US
Mailing Address - Phone:989-793-2820
Mailing Address - Fax:989-793-9132
Practice Address - Street 1:2393 SCHUST RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1334
Practice Address - Country:US
Practice Address - Phone:989-793-2820
Practice Address - Fax:989-793-9132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
MI4301040619207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180G300890OtherBLUE CROSS BLUE SHIELD
CA3610OtherRAILROAD MEDICARE
0N11610OtherMEDICARE
MI180G300890OtherBLUE CARE NETWORK
0G36036OtherMEDICARE
MI180G310710OtherBLUE CROSS BLUE SHIELD
MI180G310710OtherBLUE CARE NETWORK