Healthcare Provider Details

I. General information

NPI: 1831304765
Provider Name (Legal Business Name): EYE INSTITUTE OF SOUTH EASTERN MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10531 W JEFFERSON AVE
RIVER ROUGE MI
48218-1306
US

IV. Provider business mailing address

10531 W JEFFERSON AVE
RIVER ROUGE MI
48218-1306
US

V. Phone/Fax

Practice location:
  • Phone: 313-841-5060
  • Fax: 313-841-5060
Mailing address:
  • Phone: 313-841-5060
  • Fax: 313-841-5060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003733
License Number StateMI

VIII. Authorized Official

Name: DR. WILLIAM ABRAHAM SHAHEEN III
Title or Position: PRESIDENT
Credential: O.D.
Phone: 734-675-2079