=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669640991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRILLIUM EYE PLASTIC SURGERY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2008
-----------------------------------------------------
Last Update Date | 02/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 ASSOCIATION DR SUITE 100
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-4902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-381-8900
-----------------------------------------------------
Fax | 517-381-8830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 ASSOCIATION DR SUITE 100
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-4902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-381-8900
-----------------------------------------------------
Fax | 517-381-8830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. WILLIAM WALLACE EHRLICH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 517-381-8900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4301043309
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------