Provider Demographics
NPI:1548240930
Name:PORT HURON ENT PC
Entity Type:Organization
Organization Name:PORT HURON ENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:BRETTSCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-982-3277
Mailing Address - Street 1:1522 PINE GROVE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3382
Mailing Address - Country:US
Mailing Address - Phone:810-982-3277
Mailing Address - Fax:810-982-0716
Practice Address - Street 1:1522 PINE GROVE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3382
Practice Address - Country:US
Practice Address - Phone:810-982-3277
Practice Address - Fax:810-982-0716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICD4131OtherRR MCR
MI040G411470OtherBCBS OF MICHIGAN
MIOM60020Medicare PIN