Provider Demographics
NPI:1699051052
Name:MIDLINE VISION GROUP LLC
Entity type:Organization
Organization Name:MIDLINE VISION GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-693-2400
Mailing Address - Street 1:408 N 3RD ST STE 402
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5455
Mailing Address - Country:US
Mailing Address - Phone:608-239-1218
Mailing Address - Fax:608-467-4556
Practice Address - Street 1:412 3RD ST
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-1425
Practice Address - Country:US
Practice Address - Phone:715-693-2400
Practice Address - Fax:608-467-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
WI3146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty