Provider Demographics
NPI:1316009368
Name:TRAVERSE CITY EYE CONSULTANTS P C
Entity Type:Organization
Organization Name:TRAVERSE CITY EYE CONSULTANTS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:GUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-8101
Mailing Address - Street 1:5199 N ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9201
Mailing Address - Country:US
Mailing Address - Phone:231-935-8101
Mailing Address - Fax:231-935-0955
Practice Address - Street 1:5199 N ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9201
Practice Address - Country:US
Practice Address - Phone:231-935-8101
Practice Address - Fax:231-935-0955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207W00000X
MI332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5167610001Medicare NSC
MI0N89570Medicare PIN
MI0N89560Medicare PIN