Provider Demographics
NPI:1821279159
Name:PHILLIP A. KOHANOV O.D. PC
Entity Type:Organization
Organization Name:PHILLIP A. KOHANOV O.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOHANOV
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-985-5600
Mailing Address - Street 1:3833 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4100
Mailing Address - Country:US
Mailing Address - Phone:810-985-5600
Mailing Address - Fax:810-985-5740
Practice Address - Street 1:3833 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4100
Practice Address - Country:US
Practice Address - Phone:810-985-5600
Practice Address - Fax:810-985-5740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
900G465140OtherBLUE CROSS BLUE SHIELD
1038350001OtherREGION B DMERC
1038350001OtherREGION B DMERC
0G46514Medicare PIN