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NPI Code Detail

MEDICARE: DR. PHILLIP A KOHANOV O.D.

MEDICARE: DR. PHILLIP A KOHANOV O.D.
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
1152W00000XOptometrist4901003217MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11038350001OTHERMIREGION B DMERC
2900G465140OTHERMIBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1184615742
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. PHILLIP A KOHANOV O.D.
Provider Business Mailing Address
First Line : 3833 24TH AVE
Second Line :
City : FORT GRATIOT
State : MI
Zip : 48059-4100
Country : US
Telephone Number : 810-985-5600
Fax Number : 910-985-5740
Provider Business Practice Location Address
First Line : 3833 24TH AVE
Second Line :
City : FORT GRATIOT
State : MI
Zip : 48059-4100
Country : US
Telephone Number : 810-985-5600
Fax Number : 910-985-5740
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/02/2005
Last Update Date : 06/06/2012

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