Provider Demographics
NPI:1013085901
Name:MID MICHIGAN OPHTHALMOLOGY PC
Entity Type:Organization
Organization Name:MID MICHIGAN OPHTHALMOLOGY PC
Other - Org Name:ROSENBAUM EYE & LASER CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-393-2020
Mailing Address - Street 1:3390 EAST JOLLY ROAD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911
Mailing Address - Country:US
Mailing Address - Phone:517-393-2020
Mailing Address - Fax:517-393-5050
Practice Address - Street 1:3390 E JOLLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8547
Practice Address - Country:US
Practice Address - Phone:517-393-2020
Practice Address - Fax:517-393-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039901207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N96540Medicare PIN