Provider Demographics
NPI:1912087362
Name:MIDWEST FAMILY EYE CENTER PA
Entity Type:Organization
Organization Name:MIDWEST FAMILY EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-828-9545
Mailing Address - Street 1:7870 EXCELSIOR RD
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8427
Mailing Address - Country:US
Mailing Address - Phone:218-828-9545
Mailing Address - Fax:218-828-1572
Practice Address - Street 1:7870 EXCELSIOR RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8427
Practice Address - Country:US
Practice Address - Phone:218-828-9545
Practice Address - Fax:218-828-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN54B93MIOtherBLUE CROSS BLUE SHIELD-GLASSES
MN05N46MIOtherBLUE CROSS BLUE SHIELD, STAPLES
MNDC7353OtherRAILROAD MEDICARE
MNDD9020OtherRAILROAD MEDICARE
MN05N76MIOtherBLUE CROSS BLUE SHIELD, GLASSES, STAPLES
MN46B88MIOtherBLUE CROSS BLUE SHIELD
MN198523000Medicaid
MN05N76MIOtherBLUE CROSS BLUE SHIELD, GLASSES, STAPLES
MN1290390001Medicare NSC
MNDC7353OtherRAILROAD MEDICARE
MN198523000Medicaid