Provider Demographics
NPI:1033202023
Name:LAKESHORE EAR NOSE AND THROAT CENTER PC
Entity Type:Organization
Organization Name:LAKESHORE EAR NOSE AND THROAT CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CHIEF EXECUTIVE OFFICE
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DJ
Authorized Official - Last Name:MEGLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-779-7610
Mailing Address - Street 1:21000 E 12 MILE RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1116
Mailing Address - Country:US
Mailing Address - Phone:586-779-7610
Mailing Address - Fax:
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1116
Practice Address - Country:US
Practice Address - Phone:586-779-7610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E01107OtherBLUE SHIELD
0E06192OtherBLUE SHIELD GROUP
0M97590Medicare PIN