Basic Information
| Provider Information | |||||||||
| NPI: | 1922278977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPREHENSIVE ENT P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494234791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163962325 | ||||||||
| FaxNumber: | 6163960317 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 LINN ST | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490101525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163962325 | ||||||||
| FaxNumber: | 6163962325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2008 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | DELONG | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | WILEY | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6163962325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 4301029955 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.