Provider Demographics
NPI:1538142047
Name:EBERT, PATRICK J (OD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:EBERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1005 CHARLEVOIX DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-8186
Mailing Address - Country:US
Mailing Address - Phone:517-337-0316
Mailing Address - Fax:517-622-1205
Practice Address - Street 1:2001 COOLIDGE RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1378
Practice Address - Country:US
Practice Address - Phone:517-337-1668
Practice Address - Fax:517-337-1779
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003247152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI410033515OtherRAILROAD MEDICARE
MIPE003247OtherSTATE LICENSE NUMBER
MI2859332Medicaid
MI200000001919OtherPHPMM
MI2859332Medicaid
MI0M01930001Medicare PIN