MEDICARE: FORTNEY EYECARE ASSOCIATES

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	332H00000X	Eyewear Supplier	4901001955	MI

General Provider Information

NPI Number	:	1730332479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORTNEY EYECARE ASSOCIATES

Provider Business Mailing Address
First Line	:	23469 MICHIGAN AVE
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-1908
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23469 MICHIGAN AVE
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-1908
Country	:	US
Telephone Number	:	313-565-5600
Fax Number	:	313-562-3000

Authorized Official
Title or Position	:	BILLING
Name	:	MISS JOBETH CARILO
Credential	:
Telephone Number	:	313-565-5600

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	10/28/2008

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