Provider Demographics
NPI:1629224514
Name:SOUTH MICHIGAN OPHTHALMOLOGY P C
Entity Type:Organization
Organization Name:SOUTH MICHIGAN OPHTHALMOLOGY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-781-9822
Mailing Address - Street 1:830 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1446
Mailing Address - Country:US
Mailing Address - Phone:269-781-9822
Mailing Address - Fax:269-781-9835
Practice Address - Street 1:830 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1446
Practice Address - Country:US
Practice Address - Phone:269-781-9822
Practice Address - Fax:269-781-9835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073800261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4421664Medicaid
MI4421664Medicaid
MI0N52860Medicare PIN
MI4606030001Medicare NSC