Provider Demographics
NPI:1043542905
Name:LIVINGSTON ENT
Entity type:Organization
Organization Name:LIVINGSTON ENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JASCOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-227-3687
Mailing Address - Street 1:2300 GENOA BUSINESS PARK DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7367
Mailing Address - Country:US
Mailing Address - Phone:810-227-3687
Mailing Address - Fax:810-225-2209
Practice Address - Street 1:2300 GENOA BUSINESS PARK DR
Practice Address - Street 2:SUITE 130
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7367
Practice Address - Country:US
Practice Address - Phone:810-227-3687
Practice Address - Fax:810-225-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053044174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301053044OtherBCBS ID
MIF51824OtherUPIN
MI4301053044OtherBCBS ID