Provider Demographics
NPI:1124052337
Name:GRAND RAPIDS EAR NOSE & THROAT CENTER PLLC
Entity type:Organization
Organization Name:GRAND RAPIDS EAR NOSE & THROAT CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-575-1212
Mailing Address - Street 1:655 KENMOOR AVE SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8622
Mailing Address - Country:US
Mailing Address - Phone:616-575-1212
Mailing Address - Fax:616-575-1219
Practice Address - Street 1:655 KENMOOR AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8622
Practice Address - Country:US
Practice Address - Phone:616-575-1212
Practice Address - Fax:616-575-1219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P58750Medicare PIN