Provider Demographics
NPI:1376897157
Name:ELLICOTT CITY EYE CARE, INC.
Entity Type:Organization
Organization Name:ELLICOTT CITY EYE CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-461-7012
Mailing Address - Street 1:10176 BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-3650
Mailing Address - Country:US
Mailing Address - Phone:410-461-7012
Mailing Address - Fax:
Practice Address - Street 1:10176 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3650
Practice Address - Country:US
Practice Address - Phone:410-461-7012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD209QMedicare PIN