Provider Demographics
NPI:1548391337
Name:C B MCINNISH, OD PA
Entity Type:Organization
Organization Name:C B MCINNISH, OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:MCINNISH
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PA
Authorized Official - Phone:251-867-3635
Mailing Address - Street 1:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36427-1268
Mailing Address - Country:US
Mailing Address - Phone:251-867-3635
Mailing Address - Fax:
Practice Address - Street 1:106 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1516
Practice Address - Country:US
Practice Address - Phone:251-867-3635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-312-TA-059152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51092846OtherBLUE CROSS BLUE SHIELD
ALT68989Medicare UPIN
AL0529100001Medicare NSC