MEDICARE: MICHIGAN OPHTHALMOLOGY SPECIALISTS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist
2	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1043966955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN OPHTHALMOLOGY SPECIALISTS, PLLC

Provider Business Mailing Address
First Line	:	30150 TELEGRAPH RD STE 271
Second Line	:
City	:	BINGHAM FARMS
State	:	MI
Zip	:	48025-4521
Country	:	US
Telephone Number	:	248-395-5175
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 S ADAMS RD STE 200
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-6863
Country	:	US
Telephone Number	:	248-646-3733
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	BEVERLY ZWICKER
Credential	:
Telephone Number	:	248-395-5166

Provider Enumeration Date	:	03/01/2022
Last Update Date	:	03/01/2022

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