Provider Demographics
NPI:1740578947
Name:MICHIGAN EYE CLINIC PC
Entity Type:Organization
Organization Name:MICHIGAN EYE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:FAKIH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:313-707-6667
Mailing Address - Street 1:14726 CHAMPAIGN RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1617
Mailing Address - Country:US
Mailing Address - Phone:313-707-6667
Mailing Address - Fax:313-789-5478
Practice Address - Street 1:14726 CHAMPAIGN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1617
Practice Address - Country:US
Practice Address - Phone:313-707-6667
Practice Address - Fax:313-789-5478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5450Medicare PIN