Provider Demographics
NPI:1891855714
Name:GLAUCOMA EYE CENTER PC
Entity Type:Organization
Organization Name:GLAUCOMA EYE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-361-9205
Mailing Address - Street 1:2727 E BELTLINE AVE NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9611
Mailing Address - Country:US
Mailing Address - Phone:616-361-9205
Mailing Address - Fax:616-361-9254
Practice Address - Street 1:2727 E BELTLINE AVE NE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9611
Practice Address - Country:US
Practice Address - Phone:616-361-9205
Practice Address - Fax:616-361-9254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2013-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG53532Medicare UPIN
MI0P01740Medicare PIN
MI5524280001Medicare NSC