Provider Demographics
NPI:1902092273
Name:EASTES AND KHANUKOV MD PC
Entity type:Organization
Organization Name:EASTES AND KHANUKOV MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:EASTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-263-9999
Mailing Address - Street 1:15500 19 MILE RD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6330
Mailing Address - Country:US
Mailing Address - Phone:586-263-9999
Mailing Address - Fax:586-263-0581
Practice Address - Street 1:15500 19 MILE RD
Practice Address - Street 2:SUITE 360
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-6330
Practice Address - Country:US
Practice Address - Phone:586-263-9999
Practice Address - Fax:586-263-0581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052968207R00000X
MI4301048104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104223612Medicaid
MI104223588Medicaid
MI110E011460OtherBCBS
MI110E011460OtherBCBS
MI0M77990Medicare PIN
MIF13733Medicare UPIN