Healthcare Provider Details

I. General information

NPI: 1740252535
Provider Name (Legal Business Name): SOUTH COUNTY ENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 N SAINT JOSEPH AVE SUITE C
NILES MI
49120-2296
US

IV. Provider business mailing address

60 N SAINT JOSEPH AVE SUITE C
NILES MI
49120-2296
US

V. Phone/Fax

Practice location:
  • Phone: 269-687-2910
  • Fax: 269-687-8770
Mailing address:
  • Phone: 269-687-2910
  • Fax: 269-687-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301074195
License Number StateMI

VIII. Authorized Official

Name: MS. MARY GEEGAN MIDDLETON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 269-684-0259