Provider Demographics
NPI:1811192537
Name:RETINA VITREOUS CENTER, PC
Entity Type:Organization
Organization Name:RETINA VITREOUS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-694-6933
Mailing Address - Street 1:3181 E GRAND BLANC RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8117
Mailing Address - Country:US
Mailing Address - Phone:810-694-6933
Mailing Address - Fax:810-694-5295
Practice Address - Street 1:3181 E GRAND BLANC RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8117
Practice Address - Country:US
Practice Address - Phone:810-694-6933
Practice Address - Fax:810-694-5295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039556207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104101440Medicaid
MI102706763Medicaid
MI104101440Medicaid
MIF96502Medicare UPIN
MIA54786Medicare UPIN