Provider Demographics
NPI:1740252535
Name:SOUTH COUNTY ENT
Entity type:Organization
Organization Name:SOUTH COUNTY ENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:GEEGAN
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-684-0259
Mailing Address - Street 1:60 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2296
Mailing Address - Country:US
Mailing Address - Phone:269-687-2910
Mailing Address - Fax:269-687-8770
Practice Address - Street 1:60 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2296
Practice Address - Country:US
Practice Address - Phone:269-687-2910
Practice Address - Fax:269-687-8770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074195174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA1319OtherRAILROAD MEDICARE