Provider Demographics
NPI:1255316006
Name:OAK MOUNTAIN EYE CARE PC
Entity Type:Organization
Organization Name:OAK MOUNTAIN EYE CARE PC
Other - Org Name:VISION SOURCE MICHAEL D. BLACKBURN, O.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:205-980-5152
Mailing Address - Street 1:4960 VALLEYDALE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-4613
Mailing Address - Country:US
Mailing Address - Phone:205-980-5152
Mailing Address - Fax:205-980-5154
Practice Address - Street 1:4960 VALLEYDALE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-4613
Practice Address - Country:US
Practice Address - Phone:205-980-5152
Practice Address - Fax:205-980-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS672TA330152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51500011OtherBLUE CROSS BLUE SHIELD
P00105638OtherRAILROAD MEDICARE
AL5420270001Medicare NSC
P00105638OtherRAILROAD MEDICARE