Provider Demographics
NPI:1205006145
Name:MICHAEL G PHARRIS OD PC
Entity Type:Organization
Organization Name:MICHAEL G PHARRIS OD PC
Other - Org Name:ADVENTURE DENTAL AND VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-323-2372
Mailing Address - Street 1:2221 E BIJOU ST.
Mailing Address - Street 2:STE. 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909
Mailing Address - Country:US
Mailing Address - Phone:410-727-4746
Mailing Address - Fax:410-727-6767
Practice Address - Street 1:1253 W PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-2684
Practice Address - Country:US
Practice Address - Phone:410-727-4746
Practice Address - Fax:410-727-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD304036400Medicaid