MEDICARE: FAMILY OPTOMETRY ASSOCIATES, 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
1	152W00000X	Optometrist	4901002367	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900F36621	OTHER	MI	BLUE CROSS BLUE SHEILD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	$$$$$$$$$	OTHER	MI	SSN

General Provider Information

NPI Number	:	1972674992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY OPTOMETRY ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	2950 E WATTLES RD
Second Line	:	SUITE 100
City	:	TROY
State	:	MI
Zip	:	48085-7008
Country	:	US
Telephone Number	:	248-740-0222
Fax Number	:	248-689-0123

Provider Business Practice Location Address
First Line	:	2950 E WATTLES RD
Second Line	:	SUITE 100
City	:	TROY
State	:	MI
Zip	:	48085-7008
Country	:	US
Telephone Number	:	248-740-0222
Fax Number	:	248-689-0123

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. PHILIP DAVID COHEN
Credential	:	O.D
Telephone Number	:	248-740-0222

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	05/21/2020

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