Basic Information
| Provider Information | |||||||||
| NPI: | 1225073687 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENT SURGICAL ASSOC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27483 DEQUINDRE RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480715711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485410100 | ||||||||
| FaxNumber: | 2483993960 | ||||||||
| Practice Location | |||||||||
| Address1: | 27483 DEQUINDRE RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480715711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485410100 | ||||||||
| FaxNumber: | 2483993960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | BRANDES | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2485410100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 207YX0602X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 207YX0905X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 040F31200 | 01 | MI | BCBS MI | OTHER |