Provider Demographics
NPI:1962547984
Name:ADVANCED OPHTHALMOLOGY OF MICHIANA LLC
Entity type:Organization
Organization Name:ADVANCED OPHTHALMOLOGY OF MICHIANA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:YOUNGHEE
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-233-2114
Mailing Address - Street 1:707 N MICHIGAN ST
Mailing Address - Street 2:STE 210
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1067
Mailing Address - Country:US
Mailing Address - Phone:574-233-3474
Mailing Address - Fax:
Practice Address - Street 1:707 N MICHIGAN ST
Practice Address - Street 2:STE 210
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1067
Practice Address - Country:US
Practice Address - Phone:574-233-3474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0339800001Medicare NSC