Provider Demographics
NPI:1275588840
Name:SHELBY EYECARE ASSOCIATES PC
Entity Type:Organization
Organization Name:SHELBY EYECARE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DORAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-739-9550
Mailing Address - Street 1:48187 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-3268
Mailing Address - Country:US
Mailing Address - Phone:586-739-9550
Mailing Address - Fax:586-739-0083
Practice Address - Street 1:48187 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-3268
Practice Address - Country:US
Practice Address - Phone:586-739-9550
Practice Address - Fax:586-739-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003013152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI002109AOtherVSP GROUP NUMBER
MIP90472OtherBLUE CARE NETWORK
MI002109AOtherVSP GROUP NUMBER
MI4106170001Medicare NSC