Provider Demographics
NPI:1922069806
Name:CHILDRENS EYE CARE PC
Entity Type:Organization
Organization Name:CHILDRENS EYE CARE PC
Other - Org Name:PEDIATRIC OPHTHALMOLOGY ASSOCIATE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-561-1777
Mailing Address - Street 1:6689 ORCHARD LAKE RD # 297
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3404
Mailing Address - Country:US
Mailing Address - Phone:248-254-8140
Mailing Address - Fax:248-254-8150
Practice Address - Street 1:22731 NEWMAN ST STE 245
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2023
Practice Address - Country:US
Practice Address - Phone:313-561-1777
Practice Address - Fax:313-561-8044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-30
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1534388Medicaid
0Q24505Medicare ID - Type Unspecified