Provider Demographics
NPI:1467644732
Name:MILES W TRUMBLE MD PLLC
Entity Type:Organization
Organization Name:MILES W TRUMBLE MD PLLC
Other - Org Name:BEAR RIVER EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:W
Authorized Official - Last Name:TRUMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-487-3937
Mailing Address - Street 1:1420 PLAZA DRIVE
Mailing Address - Street 2:STE 1A
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:231-487-3937
Mailing Address - Fax:231-487-3939
Practice Address - Street 1:1420 PLAZA DRIVE
Practice Address - Street 2:STE 1A
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-487-3937
Practice Address - Fax:231-487-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMT030207207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180B410190OtherBLUE SHIELD
MI3481120Medicaid
MIP54436OtherBLUE CARE NETWORK
MIP54436OtherBLUE CARE NETWORK
MIB43065Medicare UPIN
MI3481120Medicaid