MEDICARE: EYE INSTITUTE OF SOUTH EASTERN MICHIGAN

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	4901003733	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	900H202090	OTHER	MI	BLUE CROSS PROVIDER NO.

General Provider Information

NPI Number	:	1831304765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE INSTITUTE OF SOUTH EASTERN MICHIGAN

Provider Business Mailing Address
First Line	:	10531 W JEFFERSON AVE
Second Line	:
City	:	RIVER ROUGE
State	:	MI
Zip	:	48218-1306
Country	:	US
Telephone Number	:	313-841-5060
Fax Number	:	313-841-5060

Provider Business Practice Location Address
First Line	:	10531 W JEFFERSON AVE
Second Line	:
City	:	RIVER ROUGE
State	:	MI
Zip	:	48218-1306
Country	:	US
Telephone Number	:	313-841-5060
Fax Number	:	313-841-5060

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIAM ABRAHAM SHAHEEN III
Credential	:	O.D.
Telephone Number	:	734-675-2079

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	12/07/2017

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