MEDICARE: FAMILY VISION ASSOCIATES P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900A176150	OTHER	MI	BLUE CROSS OF MICHIGAN

General Provider Information

NPI Number	:	1033302948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY VISION ASSOCIATES P.C.

Provider Business Mailing Address
First Line	:	2904 DIVISION ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2437
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2904 DIVISION ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2437
Country	:	US
Telephone Number	:	269-983-2020
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GARY GENE SISSON
Credential	:	O.D.
Telephone Number	:	269-983-2020

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	05/11/2011

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