MICHIGAN PEDIATRIC ENT ASSOCIATES, PLLC

Provider Demographics

• NPI: 1679631360
• Name: MICHIGAN PEDIATRIC ENT ASSOCIATES, PLLC
• Entity Type: Organization
• Organization Name: MICHIGAN PEDIATRIC ENT ASSOCIATES, PLLC
• Authorized Official - Title/Position: PRACTICE MANAGER
• Authorized Official - Prefix: MRS
• Authorized Official - First Name: LYNN
• Authorized Official - Last Name: DENHARDT
• Authorized Official - Phone: 248-847-3210
• Mailing Address - Street 1: 7001 ORCHARD LAKE RD
• Mailing Address - Street 2: SUITE 320C
• Mailing Address - City: WEST BLOOMFIELD
• Mailing Address - State: MI
• Mailing Address - Zip Code: 48322-3604
• Mailing Address - Country: US
• Mailing Address - Phone: 248-571-3600
• Mailing Address - Fax: 248-973-8560
• Practice Address - Street 1: 7001 ORCHARD LAKE RD
• Practice Address - Street 2: SUITE 320C
• Practice Address - City: WEST BLOOMFIELD
• Practice Address - State: MI
• Practice Address - Zip Code: 48322-3604
• Practice Address - Country: US
• Practice Address - Phone: 248-571-3600
• Practice Address - Fax: 248-973-8560
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-12-05
• Last Update Date: 2016-05-18

Provider Licenses

State	License ID	Taxonomies
MI	4301026037	207YP0228X
MI	5101010352	207YP0228X
MI	5101009481	207YP0228X
MI	4301085240	207YP0228X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207YP0228X	Allopathic & Osteopathic Physicians	Otolaryngology	Pediatric Otolaryngology	Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MI	418937910	Medicaid
MI	519222510	Medicaid
MI	418928011	Medicaid
MI	418929911	Medicaid
MI	418942111	Medicaid
MI	418935010	Medicaid
MI	519559510	Medicaid
MI	040E011990	Other	BCBS OF MI
MI	418941211	Medicaid
MI	418944011	Medicaid
MI	519253910	Medicaid
MI	418930511	Medicaid
MI	418933210	Medicaid
MI	418935010	Medicaid
MI	0N10480002	Medicare PIN
MI	0N10480005	Medicare PIN
MI	=========	Other	TAX ID#
MI	519253910	Medicaid
MI	418942111	Medicaid
MI	418930511	Medicaid
MI	B45090	Medicare UPIN
MI	0N10480003	Medicare PIN