Provider Demographics
NPI:1710963152
Name:DRS. BAALS AND WIEGAND FAMILY EYE CARE P.C.
Entity Type:Organization
Organization Name:DRS. BAALS AND WIEGAND FAMILY EYE CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:BAALS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-668-3937
Mailing Address - Street 1:240 HOOSIER DR
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-9314
Mailing Address - Country:US
Mailing Address - Phone:260-668-3937
Mailing Address - Fax:260-668-3794
Practice Address - Street 1:240 HOOSIER DR
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-9314
Practice Address - Country:US
Practice Address - Phone:260-668-3937
Practice Address - Fax:260-668-3794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN56000221A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000104867OtherANTHEM GROUP NUMBER
IN000000104867OtherANTHEM GROUP NUMBER
INT35026Medicare UPIN
INT34803Medicare UPIN
IN1180960001Medicare NSC