Healthcare Provider Details

I. General information

NPI: 1669406641
Provider Name (Legal Business Name): NORTHWEST EYE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 W OUTER DR SUITE M-106
DETROIT MI
48235-2624
US

IV. Provider business mailing address

1560 E. MAPLE RD. SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-2024
  • Fax: 313-966-7418
Mailing address:
  • Phone: 248-581-5973
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK S JUZYCH
Title or Position: MANAGER
Credential: MD
Phone: 313-577-8900