MEDICARE: GREAT LAKES EYE INSTITUTE

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
2	207W00000X	Ophthalmology Physician	4301040619	MI

General Provider Information

NPI Number	:	1447434378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES EYE INSTITUTE

Provider Business Mailing Address
First Line	:	2393 SCHUST RD
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48603-1334
Country	:	US
Telephone Number	:	989-793-2820
Fax Number	:	989-793-9132

Provider Business Practice Location Address
First Line	:	4624 HILL ST
Second Line	:
City	:	CASS CITY
State	:	MI
Zip	:	48726-1119
Country	:	US
Telephone Number	:	989-872-3800
Fax Number	:	989-872-4525

Authorized Official
Title or Position	:	OWNER/MD
Name	:	FARHAD SHOKOOHI
Credential	:	MD
Telephone Number	:	989-793-2820

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	01/23/2018

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Directions to “GREAT LAKES EYE INSTITUTE ” Practice Location

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