Provider Demographics
NPI:1043428774
Name:SOUTHERN MICHIGAN ENT P C
Entity Type:Organization
Organization Name:SOUTHERN MICHIGAN ENT P C
Other - Org Name:BROOKSIDE ENT & HEARING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BIZON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-979-6444
Mailing Address - Street 1:3600 CAPITAL AVE SW
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-9393
Mailing Address - Country:US
Mailing Address - Phone:269-979-6444
Mailing Address - Fax:
Practice Address - Street 1:3600 CAPITAL AVE SW
Practice Address - Street 2:SUITE 204
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-9393
Practice Address - Country:US
Practice Address - Phone:269-979-6444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI040A310320OtherBLUE CROSS BLUE SHIELD