Provider Demographics
NPI:1215191275
Name:ENT SURGICAL ASSOC PC
Entity Type:Organization
Organization Name:ENT SURGICAL ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ILENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-541-1620
Mailing Address - Street 1:27483 DEQUINDRE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-5711
Mailing Address - Country:US
Mailing Address - Phone:248-541-0100
Mailing Address - Fax:248-399-3960
Practice Address - Street 1:27483 DEQUINDRE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-5711
Practice Address - Country:US
Practice Address - Phone:248-541-0100
Practice Address - Fax:248-399-3960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4812649Medicaid
MI4985391Medicaid
MI640F361620OtherBCBS
MI4812630Medicaid
MI4985355Medicaid
MI5255970Medicaid
MI640F336900OtherBLUE CARE NETWORK
MI4812620Medicaid
MI640F336900OtherBCBSM
MI4985373Medicaid
MI540F336540OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI540F336540OtherBLUE CARE NETWORK
MI4985364Medicaid
MI4812602Medicaid
MI540F336540OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI540F336540OtherBLUE CARE NETWORK
MI4812630Medicaid