MEDICARE: NORTHERN EYE CARE 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	4901004595	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	6891720001	OTHER	MI	MEDICARE DMEPOS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0B20055	OTHER	MI	BCBSM

General Provider Information

NPI Number	:	1699051193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN EYE CARE ASSOCIATES, P.C.

Provider Business Mailing Address
First Line	:	200 FAIRBANKS ST
Second Line	:
City	:	IRON MOUNTAIN
State	:	MI
Zip	:	49801-1510
Country	:	US
Telephone Number	:	906-774-8280
Fax Number	:	906-774-8290

Provider Business Practice Location Address
First Line	:	200 FAIRBANKS ST
Second Line	:
City	:	IRON MOUNTAIN
State	:	MI
Zip	:	49801-1510
Country	:	US
Telephone Number	:	906-774-8280
Fax Number	:	906-774-8290

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	BEAU DAVID POQUETTE
Credential	:	O.D.
Telephone Number	:	906-774-8280

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	11/23/2016

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Directions to “NORTHERN EYE CARE ASSOCIATES, P.C. ” Practice Location

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