Provider Demographics
NPI:1780746081
Name:MICHIGAN VISION INSTITUTE PLLC
Entity type:Organization
Organization Name:MICHIGAN VISION INSTITUTE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-720-9111
Mailing Address - Street 1:5300 GATEWAY CTR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3930
Mailing Address - Country:US
Mailing Address - Phone:810-720-9111
Mailing Address - Fax:810-720-9119
Practice Address - Street 1:5300 GATEWAY CTR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3930
Practice Address - Country:US
Practice Address - Phone:810-720-9111
Practice Address - Fax:810-720-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065179207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0995895OtherHEALTHPLUS OF MICHIGAN
MIG08694OtherHAP
MI1015959OtherMCLAREN HEALTH ADV
MI4774225Medicaid
MI5100110OtherAETNA
MI1802511821OtherBCBSM
MI000000013286Medicaid
MI1802511821OtherBLUECARE NETWORK
MIC6993OtherMCARE
MIC6993OtherMCARE
MIDE2761Medicare ID - Type UnspecifiedRR MEDICARE
MI0P18290Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MI1015959OtherMCLAREN HEALTH ADV
MI1802511821OtherBCBSM
MI4774225Medicaid
MI0995895OtherHEALTHPLUS OF MICHIGAN