Provider Demographics
NPI:1619038312
Name:BIRMINGHAM VISION CARE
Entity Type:Organization
Organization Name:BIRMINGHAM VISION CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRIET
Authorized Official - Middle Name:C
Authorized Official - Last Name:PELTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-539-4800
Mailing Address - Street 1:4114 W MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3000
Mailing Address - Country:US
Mailing Address - Phone:248-539-4800
Mailing Address - Fax:248-539-4894
Practice Address - Street 1:4114 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48301
Practice Address - Country:US
Practice Address - Phone:248-539-4800
Practice Address - Fax:248-539-4894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
900F378080OtherBCBS MI
MI=========OtherEMPLOYER TAX ID
900F378080OtherBCBS MI
MI=========OtherEMPLOYER TAX ID