Provider Demographics
NPI:1083883730
Name:PETOSKEY EAR, NOSE & THROAT SPECIALISTS PLLC
Entity Type:Organization
Organization Name:PETOSKEY EAR, NOSE & THROAT SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:A
Authorized Official - Last Name:FEELEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-487-0757
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2275
Mailing Address - Country:US
Mailing Address - Phone:231-487-3277
Mailing Address - Fax:231-487-6167
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE 250
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2275
Practice Address - Country:US
Practice Address - Phone:231-487-3277
Practice Address - Fax:231-487-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000006237600000X
MI1601000140237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4923998Medicaid
MI4923989Medicaid
MI4932502Medicaid
MI4932511Medicaid