Provider Demographics
NPI:1518029909
Name:CEDAR RUN EYE CENTER, PLLC
Entity Type:Organization
Organization Name:CEDAR RUN EYE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-929-3888
Mailing Address - Street 1:3830 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8153
Mailing Address - Country:US
Mailing Address - Phone:231-929-3888
Mailing Address - Fax:231-929-4365
Practice Address - Street 1:3830 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8153
Practice Address - Country:US
Practice Address - Phone:231-929-3888
Practice Address - Fax:231-929-4365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003094152W00000X
MI4901003086152W00000X
MI4901004107152W00000X
MI4301048021207W00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900001413OtherPRIORITY - CREC
MI900B86347001OtherBCBSM
MI180B86357OtherBCBS TBH
MI900B86347003OtherBCBSM
MI1134113517OtherRAILROAD MEDICARE/CIZEK
MI900B86347OtherBCBS OPTOM GROUP
MI943166469Medicaid
MI943166487Medicaid
MICN1586OtherRAILROAD MEDICARE/CREC
MI943166496Medicaid
MI1020070001OtherDMERC REGION B
MI102022OtherPREFERRED CHOICE
MI1144214180OtherRAILROAD MEDICARE/HANLEY
MICG1308OtherRAILROAD MEDICARE/TSC
MI103164508Medicaid
MI1497736102OtherRAILROAD MEDICARE/HUMMEL
MI900001413OtherPRIORITY - CREC
MICN1586OtherRAILROAD MEDICARE/CREC