Provider Demographics
NPI:1194921692
Name:LAKESHORE EAR NOSE AND THROAT CENTER PC
Entity type:Organization
Organization Name:LAKESHORE EAR NOSE AND THROAT CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT -CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DJ
Authorized Official - Last Name:MEGLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-779-7610
Mailing Address - Street 1:21000 E 12 MILE RD
Mailing Address - Street 2:STE 111
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1116
Mailing Address - Country:US
Mailing Address - Phone:586-779-7610
Mailing Address - Fax:
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:STE 111
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1116
Practice Address - Country:US
Practice Address - Phone:586-779-7610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1108206701OtherBLUE SHIELD