Provider Demographics
NPI:1235308164
Name:MARY KAY MICHELIS MD INC
Entity Type:Organization
Organization Name:MARY KAY MICHELIS MD INC
Other - Org Name:HULL EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-945-4502
Mailing Address - Street 1:1739 W AVENUE J
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2703
Mailing Address - Country:US
Mailing Address - Phone:661-945-4502
Mailing Address - Fax:661-945-4841
Practice Address - Street 1:1739 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2703
Practice Address - Country:US
Practice Address - Phone:661-945-4502
Practice Address - Fax:661-945-4841
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HULL EYE SURGERY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS551037Medicare PIN