Provider Demographics
NPI:1649535808
Name:CADILLAC EYE CLINIC, P.C.
Entity type:Organization
Organization Name:CADILLAC EYE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-775-1248
Mailing Address - Street 1:502 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2577
Mailing Address - Country:US
Mailing Address - Phone:231-778-1248
Mailing Address - Fax:
Practice Address - Street 1:502 COBB ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2577
Practice Address - Country:US
Practice Address - Phone:231-778-1248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRB054351332H00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H34653Medicare PIN