MEDICARE: DR MARIE FOX PLC

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	4901004197	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	0C90390	OTHER	MI	BCBS PIN
3	200000030622	OTHER	MI	PHP PROVIDER NUMBER
4	0C90369	OTHER	MI	BCBS PIN

General Provider Information

NPI Number	:	1568758209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR MARIE FOX PLC

Provider Business Mailing Address
First Line	:	4855 W CENTRE AVE
Second Line	:	SUITE B
City	:	PORTAGE
State	:	MI
Zip	:	49024-4686
Country	:	US
Telephone Number	:	269-375-3937
Fax Number	:	269-375-3938

Provider Business Practice Location Address
First Line	:	4855 W CENTRE AVE
Second Line	:	SUITE B
City	:	PORTAGE
State	:	MI
Zip	:	49024-4686
Country	:	US
Telephone Number	:	269-375-3937
Fax Number	:	269-375-3938

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. MARIE L FOX
Credential	:	O.D.
Telephone Number	:	269-375-3937

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	05/12/2012

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