Provider Demographics
NPI:1073754164
Name:NORTHWEST EYE FOUNDATION
Entity Type:Organization
Organization Name:NORTHWEST EYE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:JUZYCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-581-5973
Mailing Address - Street 1:1560 E. MAPLE RD.
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5973
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:M-106
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-2024
Practice Address - Fax:313-966-7418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H24365OtherBCBSM GROUP#
MI0N24450Medicare PIN