Provider Demographics
NPI:1427090976
Name:GREAT LAKES EYE INSTITUTE
Entity type:Organization
Organization Name:GREAT LAKES EYE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:KAYVAN
Authorized Official - Last Name:SHOKOOHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-793-2820
Mailing Address - Street 1:2393 SCHUST RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1334
Mailing Address - Country:US
Mailing Address - Phone:989-793-2820
Mailing Address - Fax:989-793-9132
Practice Address - Street 1:2393 SCHUST RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1334
Practice Address - Country:US
Practice Address - Phone:989-793-2820
Practice Address - Fax:989-793-9132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010040619207W00000X
MI4301102705207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180G300890OtherFEDERAL EMPLOYEES PROGRAM BLUE CROSS
MI180G300890OtherBLUE CARE NETWORK
MI180G300890OtherBLUE CROSS BLUE SHIELD
0G36036OtherMEDICARE
MICA3610OtherRR MEDICARE
MI1807301502OtherFEDERAL BLUE CROSS
MI0G36036Medicare PIN
MI180B910450OtherFEDERAL BLUE CROSS
MI180B910450OtherBLUE CROSS
MI0M96170Medicare PIN