Birch Lake Vision Group, LLC.

Primary specialty

OptometristTaxonomy code 152W00000X

License

LD1732000 Issued in MN

Legal business name

BIRCH LAKE VISION GROUP, LLC.

Doing business as

Birch Lake Eye Clinic, Oak Tree Optical, Village Eye Clinic and Optica

Practice address

4720 White Bear Pkwy
White Bear Lake, MN 55110-3336

Phone

(651) 426-2747

Fax

(651) 426-9838

NPI assigned

Jan 25, 2007

Last updated

Dec 2, 2009By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Brian Dwight Grudem, O.D.NPI 1194717298

Title

Cfo

Phone

(651) 426-2747

Specialties & licenses 2

Addresses

Other identifiers 12

Other names 1

• Birch Lake Eye Clinic, Oak Tree Optical, Village Eye Clinic and Optica Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Brian Dwight Grudem, O.D.

  • Optometrist
  • White Bear Lake, MN
  • NPI 1194717298
  Authorized official Same address or phone

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

{
    "created_epoch": "1169683200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1259712000000",
    "number": "1609921899",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4720 WHITE BEAR PKWY",
            "city": "WHITE BEAR LAKE",
            "state": "MN",
            "postal_code": "551103336",
            "telephone_number": "651-426-2747",
            "fax_number": "651-426-9838"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4720 WHITE BEAR PKWY",
            "city": "WHITE BEAR LAKE",
            "state": "MN",
            "postal_code": "551103336",
            "telephone_number": "651-426-2747",
            "fax_number": "651-426-9838"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BIRCH LAKE VISION GROUP, LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-25",
        "last_updated": "2009-12-02",
        "status": "A",
        "authorized_official_last_name": "GRUDEM",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "DWIGHT",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "651-426-2747",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "MN",
            "license": "LD1732000",
            "primary": true
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "MN",
            "license": "LD2695000",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "244ROLU",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD RETIREM",
            "identifier": "P00116310",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA (BIRCH LAKE)",
            "identifier": "22-01733",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA (VILLAGE)",
            "identifier": "22-02779",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH PARTNERS",
            "identifier": "HP29577",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "ON456GR",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA (BIRCH LAKE)",
            "identifier": "22-02690",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED ONE",
            "identifier": "965401019270",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA (VILLAGE CLINIC)",
            "identifier": "22-02780",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH PARTNERS",
            "identifier": "HP27080",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD RETIREM",
            "identifier": "P00124841",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED ONE",
            "identifier": "965400656001",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Birch Lake Eye Clinic, Oak Tree Optical, Village Eye Clinic and Optica",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Optometrist in White Bear Lake, MN
• Providers in White Bear Lake, MN by specialty
• Optometrist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.