Provider Demographics
NPI:1326133398
Name:MID MICHIGAN EAR NOSE AND THROAT PC
Entity Type:Organization
Organization Name:MID MICHIGAN EAR NOSE AND THROAT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUS OFF MGR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TRGINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-332-0100
Mailing Address - Street 1:1500 ABBOT RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1222
Mailing Address - Country:US
Mailing Address - Phone:517-332-0100
Mailing Address - Fax:517-332-0356
Practice Address - Street 1:1500 ABBOT RD
Practice Address - Street 2:SUITE 400
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1222
Practice Address - Country:US
Practice Address - Phone:517-332-0100
Practice Address - Fax:517-332-0356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI040C310470OtherBCBS OF MI/PROVIDER GROUP
MIM4359000Medicare ID - Type UnspecifiedMEDICARE GROUP ID #