Provider Demographics
NPI:1215175385
Name:MID MICHIGAN RETINA PLC
Entity type:Organization
Organization Name:MID MICHIGAN RETINA PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIXIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-455-7545
Mailing Address - Street 1:1070 TROWBRIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5220
Mailing Address - Country:US
Mailing Address - Phone:517-574-5850
Mailing Address - Fax:517-574-5852
Practice Address - Street 1:1070 TROWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5220
Practice Address - Country:US
Practice Address - Phone:517-574-5850
Practice Address - Fax:517-574-5852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068962207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH38016Medicare UPIN