Provider Demographics
NPI:1083653497
Name:MICHAEL L SUSSEX OD PC
Entity Type:Organization
Organization Name:MICHAEL L SUSSEX OD PC
Other - Org Name:SUSSEX VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUSSEX
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-651-2960
Mailing Address - Street 1:350 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036
Mailing Address - Country:US
Mailing Address - Phone:517-278-6303
Mailing Address - Fax:517-279-8000
Practice Address - Street 1:706 S CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091
Practice Address - Country:US
Practice Address - Phone:269-651-2960
Practice Address - Fax:269-657-4333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL L SUSSEX OD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI941776997Medicaid
MI900A210070OtherBCBS
MI0M60150Medicare PIN
MI941776997Medicaid