Provider Demographics
NPI:1386711547
Name:ASSOCIATED EYE PHYSICIANS OF DEARBORN PC
Entity type:Organization
Organization Name:ASSOCIATED EYE PHYSICIANS OF DEARBORN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:CHASE
Authorized Official - Last Name:GRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-582-8856
Mailing Address - Street 1:15212 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3497
Mailing Address - Country:US
Mailing Address - Phone:313-582-8856
Mailing Address - Fax:313-582-8265
Practice Address - Street 1:15212 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3497
Practice Address - Country:US
Practice Address - Phone:313-582-8856
Practice Address - Fax:313-582-8265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0792390001Medicare PIN
MI0Q26255Medicare PIN