MEDICARE: UNIVERSITY OTOLARYNGOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0H22557	OTHER	MI	BCBSM GROUP NUMBER

General Provider Information

NPI Number	:	1720103112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OTOLARYNGOLOGY

Provider Business Mailing Address
First Line	:	3800 WOODWARD AVE
Second Line	:	SUITE 600
City	:	DETROIT
State	:	MI
Zip	:	48201-2061
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	43494 WOODWARD AVE
Second Line	:	SUITE 210
City	:	BLOOMFIELD TOWNSHIP
State	:	MI
Zip	:	48302-5052
Country	:	US
Telephone Number	:	248-335-9800
Fax Number	:

Authorized Official
Title or Position	:	COORDINATOR
Name	:	SHARON BRANKA
Credential	:
Telephone Number	:	313-745-1740

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	08/22/2020

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Directions to “UNIVERSITY OTOLARYNGOLOGY ” Practice Location

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