Provider Demographics
NPI:1144511312
Name:GENESEE ENT ASSOCIATES, PC
Entity type:Organization
Organization Name:GENESEE ENT ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKAIRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-742-0225
Mailing Address - Street 1:1501 S CENTER RD
Mailing Address - Street 2:BLDG B
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1731
Mailing Address - Country:US
Mailing Address - Phone:810-742-0225
Mailing Address - Fax:810-742-7990
Practice Address - Street 1:1501 S CENTER RD
Practice Address - Street 2:BLDG B
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1731
Practice Address - Country:US
Practice Address - Phone:810-742-0225
Practice Address - Fax:810-742-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000320332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1601000320OtherSTATE OF MICHIGAN MI HEALTH PROF LICENSE
MI805367063Medicaid