Provider Demographics
NPI:1912086281
Name:BAIN, MIKE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:BAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5649
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-0649
Mailing Address - Country:US
Mailing Address - Phone:989-797-2400
Mailing Address - Fax:989-249-1035
Practice Address - Street 1:5161 CARDINAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9435
Practice Address - Country:US
Practice Address - Phone:989-797-2400
Practice Address - Fax:989-249-1035
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMB000027156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4296145Medicaid
MIMB000027OtherSTATE LICENCE