Provider Demographics
NPI:1649275041
Name:MID MICHIGAN EYE CARE CENTER, PC
Entity type:Organization
Organization Name:MID MICHIGAN EYE CARE CENTER, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-841-3007
Mailing Address - Street 1:850 W. NORTH STREET
Mailing Address - Street 2:STE. 104
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3196
Mailing Address - Country:US
Mailing Address - Phone:877-852-8463
Mailing Address - Fax:517-817-0144
Practice Address - Street 1:1116 W. GANSON STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-4240
Practice Address - Country:US
Practice Address - Phone:877-852-8463
Practice Address - Fax:517-817-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207WX0107X, 207W00000X
MI4301034151207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICC5220OtherRAILROAD MEDICARE
900H115380OtherBCBSM
MI180C846310OtherBCBSM
MI180H149970OtherBCBSM
MI900C848370OtherBCBSM
MIC31544OtherRAILROAD MEDICARE
MI900N834800OtherBCBSM
MIC31544OtherRAILROAD MEDICARE
MI900N834800OtherBCBSM
MI900C848370OtherBCBSM
MI0C84837Medicare PIN