Provider Demographics
NPI:1952529588
Name:OGAWA MACOMB EYE CENTER, P.C.
Entity Type:Organization
Organization Name:OGAWA MACOMB EYE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARLOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-558-5010
Mailing Address - Street 1:11900 12 MILE ROAD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093
Mailing Address - Country:US
Mailing Address - Phone:586-558-5010
Mailing Address - Fax:586-558-5013
Practice Address - Street 1:11900 12 MILE ROAD
Practice Address - Street 2:SUITE 206
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-558-5010
Practice Address - Fax:586-558-5013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAO029327207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2878481Medicaid
MI1805001581OtherBLUE CROSS BLUE SHIELD
MIP40293OtherBLUE CARE NETWORK
MI0824440001Medicare NSC
MI0500158Medicare ID - Type Unspecified
MI2878481Medicaid