Provider Demographics
NPI:1831304765
Name:EYE INSTITUTE OF SOUTH EASTERN MICHIGAN
Entity Type:Organization
Organization Name:EYE INSTITUTE OF SOUTH EASTERN MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ABRAHAM
Authorized Official - Last Name:SHAHEEN
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:734-675-2079
Mailing Address - Street 1:10531 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218-1306
Mailing Address - Country:US
Mailing Address - Phone:313-841-5060
Mailing Address - Fax:313-841-5060
Practice Address - Street 1:10531 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1306
Practice Address - Country:US
Practice Address - Phone:313-841-5060
Practice Address - Fax:313-841-5060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3475571Medicaid
MI900H202090OtherBLUE CROSS PROVIDER NO.
MIU52139Medicare UPIN
MI3475571Medicaid
MI900H202090OtherBLUE CROSS PROVIDER NO.
MI0N84340Medicare PIN