Provider Demographics
NPI:1689918120
Name:HILLSDALE OPTOMETRY PC
Entity Type:Organization
Organization Name:HILLSDALE OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CORBETT
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBURGEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:1517-437-3365
Mailing Address - Street 1:43 S HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-1851
Mailing Address - Country:US
Mailing Address - Phone:517-437-3365
Mailing Address - Fax:517-437-3656
Practice Address - Street 1:43 S HOWELL ST
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-1851
Practice Address - Country:US
Practice Address - Phone:517-437-3365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4539708Medicaid
MIU97635Medicare UPIN
MI4539708Medicaid
MI6877730001Medicare PIN