Healthcare Provider Details

I. General information

NPI: 1083907992
Provider Name (Legal Business Name): MICHIANA EYE CENTER , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216 CASSOPOLIS ST
ELKHART IN
46514
US

IV. Provider business mailing address

230 E DAY RD STE 100
MISHAWAKA IN
46545-3408
US

V. Phone/Fax

Practice location:
  • Phone: 574-266-2111
  • Fax: 574-266-0555
Mailing address:
  • Phone: 574-271-3939
  • Fax: 574-271-3941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN R BAXTER
Title or Position: OWNER/OPHTHALMOLOGISTS
Credential: DO
Phone: 574-271-3939