MEDICARE: MID MICHIGAN FAMILY EYE CARE 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	4901004640	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0A80041	OTHER	MI	BLUECROSS BLUESHIED

General Provider Information

NPI Number	:	1356698534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID MICHIGAN FAMILY EYE CARE PLLC

Provider Business Mailing Address
First Line	:	PO BOX 505
Second Line	:
City	:	BEAVERTON
State	:	MI
Zip	:	48612-0505
Country	:	US
Telephone Number	:	989-435-2020
Fax Number	:	989-435-2554

Provider Business Practice Location Address
First Line	:	334 N ROSS ST
Second Line	:
City	:	BEAVERTON
State	:	MI
Zip	:	48612-8165
Country	:	US
Telephone Number	:	989-435-2020
Fax Number	:	989-435-2554

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. BRIAN MICHAEL HALES
Credential	:	O.D.
Telephone Number	:	989-435-2020

Provider Enumeration Date	:	08/07/2012
Last Update Date	:	06/28/2013

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