Provider Demographics
NPI:1154365849
Name:WEST MICHIGAN EAR NOSE & THROAT PLC
Entity type:Organization
Organization Name:WEST MICHIGAN EAR NOSE & THROAT PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMYE
Authorized Official - Middle Name:LATRECE
Authorized Official - Last Name:GADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-327-7200
Mailing Address - Street 1:3850 GLENKERRY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-327-7200
Mailing Address - Fax:269-327-9272
Practice Address - Street 1:3850 GLENKERRY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-327-7200
Practice Address - Fax:269-327-9272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDR009649207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI4416Medicare PIN