Healthcare Provider Details

I. General information

NPI: 1083659932
Provider Name (Legal Business Name): CENTER FOR EAR,NOSE AND THROAT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HAGGERTY ROAD SUITE 2130
WEST BLOOMFIELD MI
48323
US

IV. Provider business mailing address

2300 HAGGERTY RD STE 2130
WEST BLOOMFIELD MI
48323-2191
US

V. Phone/Fax

Practice location:
  • Phone: 248-668-1104
  • Fax: 248-668-1096
Mailing address:
  • Phone: 248-668-1104
  • Fax: 248-668-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number5101010029
License Number StateMI

VIII. Authorized Official

Name: STEVEN JOE KIN
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 248-668-1104