Healthcare Provider Details

I. General information

NPI: 1659591204
Provider Name (Legal Business Name): KENT OTOLARYNGOLOGY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 FULTON ST E
GRAND RAPIDS MI
49503-3211
US

IV. Provider business mailing address

222 FULTON ST E PO BOX 1983
GRAND RAPIDS MI
49503-3211
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7455
  • Fax:
Mailing address:
  • Phone: 616-459-7455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301030445
License Number StateMI

VIII. Authorized Official

Name: THOMAS SPOONER
Title or Position: PRESIDENT
Credential: MD
Phone: 616-459-7455