1760572978 NPI number — MICHIGAN OTOLARYNGOLGY SURGERY

Table of content: (NPI 1760572978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760572978 NPI number — MICHIGAN OTOLARYNGOLGY SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN OTOLARYNGOLGY SURGERY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760572978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5333 MCAULEY DR
Provider Second Line Business Mailing Address:
SUITE 2017
Provider Business Mailing Address City Name:
YPSILANTI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48197-1014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-851-6672
Provider Business Mailing Address Fax Number:
734-712-3358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5333 MCAULEY DR
Provider Second Line Business Practice Location Address:
SUITE 2017
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-851-6672
Provider Business Practice Location Address Fax Number:
734-712-3358
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STUTZ
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
DIRECTOR OF AUDIOLOGY
Authorized Official Telephone Number:
800-851-6672

Provider Taxonomy Codes

  • Taxonomy code: 237600000X , with the licence number:  1601000018 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 540H110290 . This is a "BLUE CROSS DISPENSING" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0H16076 . This is a "MI BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: B6940 . This is a "MCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0H16076 . This is a "BLUECROSS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 640H110290 . This is a "BLUE CROSS HEARING&VISION" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 108202 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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