Provider Demographics
NPI:1184123150
Name:GREAT LAKES EAR NOSE & THROAT SPECIALISTS PC
Entity type:Organization
Organization Name:GREAT LAKES EAR NOSE & THROAT SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIETZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-838-1571
Mailing Address - Street 1:1114 CHARLEVOIX AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9701
Mailing Address - Country:US
Mailing Address - Phone:231-489-8151
Mailing Address - Fax:231-668-7794
Practice Address - Street 1:1114 CHARLEVOIX AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9701
Practice Address - Country:US
Practice Address - Phone:231-489-8151
Practice Address - Fax:231-668-7794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013761207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty