MEDICARE: PORT HURON OPHTHALMOLOGY, PLLC

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	207W00000X	Ophthalmology Physician	BF064615	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	180G412660	OTHER	MI	BCBSM GRP
2	180028563	OTHER	MI	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1376558122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT HURON OPHTHALMOLOGY, PLLC

Provider Business Mailing Address
First Line	:	1660 STONE ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3344
Country	:	US
Telephone Number	:	810-985-9600
Fax Number	:	810-985-9244

Provider Business Practice Location Address
First Line	:	1660 STONE ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3344
Country	:	US
Telephone Number	:	810-985-9600
Fax Number	:	810-985-9244

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. BRENDA JEAN FAVERO
Credential	:
Telephone Number	:	810-985-9600

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	11/24/2021

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