Provider Demographics
NPI:1245384544
Name:STADIUM OPTICIANS, INC.
Entity Type:Organization
Organization Name:STADIUM OPTICIANS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:MELDRUM
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:734-663-0870
Mailing Address - Street 1:2333 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3844
Mailing Address - Country:US
Mailing Address - Phone:734-663-0870
Mailing Address - Fax:734-761-5242
Practice Address - Street 1:2333 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3844
Practice Address - Country:US
Practice Address - Phone:734-663-0870
Practice Address - Fax:734-761-5242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003645152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900H16511OtherBCBS OF MI VISION
MION88110Medicare ID - Type Unspecified