Provider Demographics
NPI:1174748081
Name:RIVERSIDE EYE CENTER PC
Entity type:Organization
Organization Name:RIVERSIDE EYE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-385-7200
Mailing Address - Street 1:4050 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EAST CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-2908
Mailing Address - Country:US
Mailing Address - Phone:810-329-9045
Mailing Address - Fax:810-329-8732
Practice Address - Street 1:4050 RIVER RD
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2908
Practice Address - Country:US
Practice Address - Phone:810-329-9045
Practice Address - Fax:810-329-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1146090001332B00000X
MI207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180G410170OtherBCBS PIN
MI0741045OtherBCBS INDIVIDUAL PIN
MI0M78860Medicare PIN
MI180G410170OtherBCBS PIN
MI1146090001Medicare NSC