Port Huron Ophthalmology, PLLC

Primary specialty

Ophthalmology PhysicianTaxonomy code 207W00000X

License

BF064615 Issued in MI

Legal business name

PORT HURON OPHTHALMOLOGY, PLLC

Practice address

1660 Stone St
Port Huron, MI 48060-3344

Phone

(810) 985-9600

Fax

(810) 985-9244

NPI assigned

Jul 30, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Brenda Jean Favero

Title

Administrator

Phone

(810) 985-9600

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Brian Val Favero, M.D.

  • Ophthalmology Physician
  • Port Huron, MI
  • NPI 1639130024
  Medicare reassignment NPD
• Michelle Kornblum, MD

  • Ophthalmology Physician
  • Livonia, MI
  • NPI 1093019465
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154217600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1637712000000",
    "number": "1376558122",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1660 STONE ST",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603344",
            "telephone_number": "810-985-9600",
            "fax_number": "810-985-9244"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1660 STONE ST",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603344",
            "telephone_number": "810-985-9600",
            "fax_number": "810-985-9244"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORT HURON OPHTHALMOLOGY, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-30",
        "last_updated": "2021-11-24",
        "certification_date": "2021-11-24",
        "status": "A",
        "authorized_official_last_name": "FAVERO",
        "authorized_official_first_name": "BRENDA",
        "authorized_official_middle_name": "JEAN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "810-985-9600",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology",
            "state": "MI",
            "license": "BF064615",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSM GRP",
            "identifier": "180G412660",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTHCARE",
            "identifier": "180028563",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Port Huron Family Care PLLC
• Port Huron Hospital Crna Billing, LLC
• Port Huron Internal Medicine
• Port Huron Internal Medicine Associates
• Port Huron Mercy Family Care Inc
• Port Huron Pharmacy, LLC
• Port Huron Vascular Clinic PC
• Ramona Dolores Portis, CASE MANAGER-CAC-M
• Emily Amanda Porzondek, PMHNP
• Jadean Ireland Potter, LMSW

• Ophthalmology Physician in Port Huron, MI
• Providers in Port Huron, MI by specialty
• Ophthalmology Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.