Provider Demographics
NPI:1780980516
Name:MIDWEST EYE CONSULTANTS, PC
Entity type:Organization
Organization Name:MIDWEST EYE CONSULTANTS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES./CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-569-9550
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-9244
Practice Address - Street 1:220 N IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2518
Practice Address - Country:US
Practice Address - Phone:574-289-3937
Practice Address - Fax:574-280-7355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST EYE CONSULTANTS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-26
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN56000164A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100082470VMedicaid
IN452570Medicare PIN
IN0317020035Medicare NSC
INM100042614Medicare PIN