Provider Demographics
NPI:1093979742
Name:MARC L AUSTHOF OD EYE CARE SERVICES PLLC
Entity Type:Organization
Organization Name:MARC L AUSTHOF OD EYE CARE SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:AUSTHOF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-933-7195
Mailing Address - Street 1:2640 CROSSING CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7930
Mailing Address - Country:US
Mailing Address - Phone:231-933-7195
Mailing Address - Fax:231-933-7197
Practice Address - Street 1:2640 CROSSING CIR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7930
Practice Address - Country:US
Practice Address - Phone:231-933-7195
Practice Address - Fax:231-933-7197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003842152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M75970Medicare PIN
MIU73692Medicare UPIN