Healthcare Provider Details

I. General information

NPI: 1992032338
Provider Name (Legal Business Name): GENESEE ENT ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CENTER RD BLDG B
BURTON MI
48509-1731
US

IV. Provider business mailing address

1501 S CENTER RD BLDG B
BURTON MI
48509-1731
US

V. Phone/Fax

Practice location:
  • Phone: 810-742-0225
  • Fax: 810-742-7990
Mailing address:
  • Phone: 810-742-0225
  • Fax: 810-742-7990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number4301085139
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number4301037118
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1601000320
License Number StateMI

VIII. Authorized Official

Name: DR. KHALED M SHUKAIRY
Title or Position: OWNER
Credential: MD
Phone: 810-742-0225