Healthcare Provider Details

I. General information

NPI: 1124052337
Provider Name (Legal Business Name): GRAND RAPIDS EAR NOSE & THROAT CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 KENMOOR AVE SE SUITE A
GRAND RAPIDS MI
49546-8622
US

IV. Provider business mailing address

655 KENMOOR AVE SE SUITE A
GRAND RAPIDS MI
49546-8622
US

V. Phone/Fax

Practice location:
  • Phone: 616-575-1212
  • Fax: 616-575-1219
Mailing address:
  • Phone: 616-575-1212
  • Fax: 616-575-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN MICHAEL KOSTA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 616-575-1212