Provider Demographics
NPI:1922278977
Name:COMPREHENSIVE ENT P.C.
Entity Type:Organization
Organization Name:COMPREHENSIVE ENT P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:WILEY
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-396-2325
Mailing Address - Street 1:111 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4791
Mailing Address - Country:US
Mailing Address - Phone:616-396-2325
Mailing Address - Fax:616-396-0317
Practice Address - Street 1:516 LINN ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1525
Practice Address - Country:US
Practice Address - Phone:616-396-2325
Practice Address - Fax:616-396-2325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029955207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0G07623Medicare PIN
A78114Medicare UPIN