Basic Information
| Provider Information | |||||||||
| NPI: | 1255364931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENTS OF THE UNIVERSITY OF MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST - PROVIDER ENROLLMENT | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 320 WEST COMMERCE ROAD | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486847337 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | SPAHLINGER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXEC MEDICAL DIRECTOR FACULTY GRP | ||||||||
| AuthorizedOfficialTelephone: | 7349364000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENTS OF THE UNIVERSITY OF MICHIGAN | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 540F329460 | 01 | MI | BCBS DMER # | OTHER |