Provider Demographics
NPI:1760586861
Name:NORTHLAND RETINA ASSOC
Entity Type:Organization
Organization Name:NORTHLAND RETINA ASSOC
Other - Org Name:OAKLAND RETINA CONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HEYNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-569-0131
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:STE 607
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-569-0131
Mailing Address - Fax:248-569-0132
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:STE 607
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-569-0131
Practice Address - Fax:248-569-0132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301023890207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B44623Medicare UPIN
0633897Medicare ID - Type Unspecified