Provider Demographics
NPI:1265426514
Name:GRAND TRAVERSE OPHTHALMOLOGY CLINIC PC
Entity type:Organization
Organization Name:GRAND TRAVERSE OPHTHALMOLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MUSSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-932-4336
Mailing Address - Street 1:929 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-8683
Mailing Address - Country:US
Mailing Address - Phone:231-947-6246
Mailing Address - Fax:231-947-8864
Practice Address - Street 1:929 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-8683
Practice Address - Country:US
Practice Address - Phone:231-947-6246
Practice Address - Fax:231-947-8864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C86342Medicare PIN