Provider Demographics
NPI:1164960571
Name:MICHIGAN RETINA CENTER, PC
Entity Type:Organization
Organization Name:MICHIGAN RETINA CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ASHEESH
Authorized Official - Middle Name:
Authorized Official - Last Name:TEWARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-441-2227
Mailing Address - Street 1:25230 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1715
Mailing Address - Country:US
Mailing Address - Phone:313-441-2227
Mailing Address - Fax:313-441-2241
Practice Address - Street 1:25230 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1715
Practice Address - Country:US
Practice Address - Phone:313-441-2227
Practice Address - Fax:313-441-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078018207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty