Provider Demographics
NPI:1184978272
Name:SUPERIOR EAR, NOSE & THROAT SPECIALISTS, PC
Entity type:Organization
Organization Name:SUPERIOR EAR, NOSE & THROAT SPECIALISTS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEICHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-225-7660
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-7660
Mailing Address - Fax:906-225-7665
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-7660
Practice Address - Fax:906-225-7665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000071332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4865320Medicaid
MIOE21137OtherBCBS
MI0P26560Medicare PIN