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General NPI Number Information
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NPI Number | 1649275041
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Entity Type | Organization
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Legal Business Name | MID MICHIGAN EYE CARE CENTER, PC
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Dates
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Enumeration Date | 06/14/2005
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Last Update Date | 11/26/2018
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Provider Practice Location Address
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Address Line | 1116 W. GANSON STREET
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City | JACKSON
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State | MI
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Zip | 49202-4240
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Country | US
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Telephone | 877-852-8463
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Fax | 517-817-0144
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Provider Business Mailing Address
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Address Line | 850 W. NORTH STREET STE. 104
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City | JACKSON
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State | MI
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Zip | 49202-3196
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Country | US
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Telephone | 877-852-8463
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Fax | 517-817-0144
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Authorized Official
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Title or Position | CEO
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Name | MR. THOMAS T ROARK
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Credential |
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Telephone | 517-841-3007
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 4301034151
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 207WX0107X
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Taxonomy Name | Retina Specialist (Ophthalmology) Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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