Basic Information
| Provider Information | |||||||||
| NPI: | 1215191275 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENT SURGICAL ASSOC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27483 DEQUINDRE RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480715711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485410100 | ||||||||
| FaxNumber: | 2483993960 | ||||||||
| Practice Location | |||||||||
| Address1: | 27483 DEQUINDRE RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480715711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485410100 | ||||||||
| FaxNumber: | 2483993960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILES | ||||||||
| AuthorizedOfficialFirstName: | ILENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2485411620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 4812649 | 05 | MI | MEDICAID | 4985391 | 05 | MI | MEDICAID | 640F361620 | 01 | MI | BCBS | OTHER | 4812630 | 05 | MI | MEDICAID | 4985355 | 05 | MI | MEDICAID | 5255970 | 05 | MI | MEDICAID | 640F336900 | 01 | MI | BLUE CARE NETWORK | OTHER | 4812620 | 05 | MI | MEDICAID | 640F336900 | 01 | MI | BCBSM | OTHER | 4985373 | 05 | MI | MEDICAID | 540F336540 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER | 540F336540 | 01 | MI | BLUE CARE NETWORK | OTHER | 4985364 | 05 | MI | MEDICAID | 4812602 | 05 | MI | MEDICAID |