Provider Demographics
NPI:1831174879
Name:CADILLAC EYE CLINIC PC
Entity type:Organization
Organization Name:CADILLAC EYE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BRENZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-775-1248
Mailing Address - Street 1:502 COBBS 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:231-775-1248
Mailing Address - Fax:231-775-1156
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:231-775-1248
Practice Address - Fax:231-775-1156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180H34653OtherBCBSM
MI3255157Medicaid
MI180H34653OtherBCBSM
0H34653Medicare ID - Type Unspecified