Provider Demographics
NPI:1609921899
Name:BIRCH LAKE VISION GROUP, LLC.
Entity Type:Organization
Organization Name:BIRCH LAKE VISION GROUP, LLC.
Other - Org Name:BIRCH LAKE EYE CLINIC, OAK TREE OPTICAL, VILLAGE EYE CLINIC AND OPTICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:GRUDEM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-426-2747
Mailing Address - Street 1:4720 WHITE BEAR PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3336
Mailing Address - Country:US
Mailing Address - Phone:651-426-2747
Mailing Address - Fax:651-426-9838
Practice Address - Street 1:4720 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3336
Practice Address - Country:US
Practice Address - Phone:651-426-2747
Practice Address - Fax:651-426-9838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD1732000152W00000X
MNLD2695000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22-01733OtherMEDICA (BIRCH LAKE)
MN244ROLUOtherBLUE CROSS BLUE SHIELD
MNP00116310OtherMEDICARE RAILROAD RETIREM
MNP00124841OtherMEDICARE RAILROAD RETIREM
MN22-02690OtherMEDICA (BIRCH LAKE)
MN965401019270OtherPREFERRED ONE
MN22-02779OtherMEDICA (VILLAGE)
MNHP29577OtherHEALTH PARTNERS
MNON456GROtherBCBS
MN22-02780OtherMEDICA (VILLAGE CLINIC)
MN965400656001OtherPREFERRED ONE
MNHP27080OtherHEALTH PARTNERS
MN22-02780OtherMEDICA (VILLAGE CLINIC)
MNT39581Medicare UPIN
5158010001Medicare NSC
MN22-01733OtherMEDICA (BIRCH LAKE)
MNU74340Medicare UPIN