Provider Demographics
NPI:1760572978
Name:MICHIGAN OTOLARYNGOLGY SURGERY
Entity Type:Organization
Organization Name:MICHIGAN OTOLARYNGOLGY SURGERY
Other - Org Name:MOSA AUDIOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF AUDIOLOGY
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:STUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:800-851-6672
Mailing Address - Street 1:5333 MCAULEY DR
Mailing Address - Street 2:SUITE 2017
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1014
Mailing Address - Country:US
Mailing Address - Phone:800-851-6672
Mailing Address - Fax:734-712-3358
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE 2017
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:800-851-6672
Practice Address - Fax:734-712-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000018237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540H110290OtherBLUE CROSS DISPENSING
MI0H16076OtherMI BCN
MAB6940OtherMCARE
MI0H16076OtherBLUECROSS OF MI
MI640H110290OtherBLUE CROSS HEARING&VISION
MI108202OtherCARE CHOICES
MI108202OtherCARE CHOICES
MI540H110290OtherBLUE CROSS DISPENSING