Provider Demographics
NPI:1912118563
Name:EYE & ENT SPECIALISTS
Entity Type:Organization
Organization Name:EYE & ENT SPECIALISTS
Other - Org Name:CREEKSIDE HEARING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:NOSANOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-945-3888
Mailing Address - Street 1:1761 W M 43 HWY
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-8378
Mailing Address - Country:US
Mailing Address - Phone:269-945-3888
Mailing Address - Fax:269-945-2112
Practice Address - Street 1:1761 W M 43 HWY
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-8378
Practice Address - Country:US
Practice Address - Phone:269-945-3888
Practice Address - Fax:269-945-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMN053930332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI805186836Medicaid
MIP04740006Medicare PIN