Provider Demographics
NPI:1669640991
Name:TRILLIUM EYE PLASTIC SURGERY, P.C.
Entity Type:Organization
Organization Name:TRILLIUM EYE PLASTIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:EHRLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-381-8900
Mailing Address - Street 1:2211 ASSOCIATION DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4902
Mailing Address - Country:US
Mailing Address - Phone:517-381-8900
Mailing Address - Fax:517-381-8830
Practice Address - Street 1:2211 ASSOCIATION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4902
Practice Address - Country:US
Practice Address - Phone:517-381-8900
Practice Address - Fax:517-381-8830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043309174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA74882Medicare UPIN