Healthcare Provider Details

I. General information

NPI: 1194921692
Provider Name (Legal Business Name): LAKESHORE EAR NOSE AND THROAT CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 E 12 MILE RD STE 111
SAINT CLAIR SHORES MI
48081-1116
US

IV. Provider business mailing address

21000 E 12 MILE RD STE 111
SAINT CLAIR SHORES MI
48081-1116
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-7610
  • Fax:
Mailing address:
  • Phone: 586-779-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL DJ MEGLER
Title or Position: PRESIDENT -CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 586-779-7610