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NPI Code Detail

MEDICARE: PHILLIP A. KOHANOV O.D. PC

MEDICARE: PHILLIP A. KOHANOV O.D. PC
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
1152W00000XOptometrist

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1900G465140OTHERBLUE CROSS BLUE SHIELD
21038350001OTHERREGION B DMERC

General Provider Information

NPI Number : 1821279159
Entity Type Code : Organization
Provider Name (Legal Business Name) : PHILLIP A. KOHANOV O.D. PC
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 : 810-985-5740
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 : 810-985-5740
Authorized Official
Title or Position : OPTOMETRIST
Name : DR. PHILLIP A. KOHANOV
Credential : O.D.
Telephone Number : 810-985-5600
Provider Enumeration Date : 11/15/2007
Last Update Date : 06/05/2012

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Practice Location Address:
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