Provider Demographics
NPI:1164552972
Name:GREAT LAKES EYE CONSULTANTS PLC
Entity Type:Organization
Organization Name:GREAT LAKES EYE CONSULTANTS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-947-1690
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:ACME
Mailing Address - State:MI
Mailing Address - Zip Code:49610-0308
Mailing Address - Country:US
Mailing Address - Phone:231-947-1690
Mailing Address - Fax:231-947-1692
Practice Address - Street 1:872 MUNSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-947-1690
Practice Address - Fax:231-947-1692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061885207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104609642Medicaid
MI104609651Medicaid
MI104609660Medicaid
MI104609633Medicaid
MI104609642Medicaid
MI0N95760Medicare PIN
MIH26737Medicare UPIN