Provider Demographics
NPI:1912176892
Name:SCARBROUGH PROFESSIONAL SERVICES, P.C.
Entity Type:Organization
Organization Name:SCARBROUGH PROFESSIONAL SERVICES, P.C.
Other - Org Name:SCARBROUGH FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SCARBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-947-8667
Mailing Address - Street 1:527 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2207
Mailing Address - Country:US
Mailing Address - Phone:231-947-8667
Mailing Address - Fax:
Practice Address - Street 1:527 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2207
Practice Address - Country:US
Practice Address - Phone:231-947-8667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3071759Medicaid
MI0B86520Medicare PIN
MIDS3120Medicare PIN
MI0185420001Medicare NSC