Healthcare Provider Details

I. General information

NPI: 1356394803
Provider Name (Legal Business Name): NORTHWOODS EAR, NOSE & THROAT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 CHARLEVOIX AVE
PETOSKEY MI
49770-8524
US

IV. Provider business mailing address

2611 CHARLEVOIX AVE
PETOSKEY MI
49770-8524
US

V. Phone/Fax

Practice location:
  • Phone: 231-348-5900
  • Fax: 231-348-5901
Mailing address:
  • Phone: 231-348-5900
  • Fax: 231-348-5901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number5101015870
License Number StateMI

VIII. Authorized Official

Name: JAMES J SLATER
Title or Position: OWNER
Credential: D.O.
Phone: 231-348-5900