Provider Demographics
NPI:1366643538
Name:ALLEGAN EYECARE PC
Entity Type:Organization
Organization Name:ALLEGAN EYECARE PC
Other - Org Name:HODGE & WOOD INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ANTON
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-673-5100
Mailing Address - Street 1:123 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010
Mailing Address - Country:US
Mailing Address - Phone:269-673-5100
Mailing Address - Fax:269-673-1806
Practice Address - Street 1:123 LOCUST ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010
Practice Address - Country:US
Practice Address - Phone:269-673-5100
Practice Address - Fax:269-673-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003016152W00000X
MI4901003042152WV0400X
MI152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
900Z310140OtherBCBS OF MICHIGAN
MI944193774Medicaid
MI944340860Medicaid
MI0M92240Medicare ID - Type Unspecified
900Z310140OtherBCBS OF MICHIGAN
MIU26112Medicare UPIN
MI0265210001Medicare NSC