Provider Demographics
NPI:1003273129
Name:GREAT LAKES SURGERY CENTER LLC
Entity Type:Organization
Organization Name:GREAT LAKES SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:N
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-428-3300
Mailing Address - Street 1:2848 NILES RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3352
Mailing Address - Country:US
Mailing Address - Phone:269-428-3304
Mailing Address - Fax:
Practice Address - Street 1:2848 NILES RD
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3352
Practice Address - Country:US
Practice Address - Phone:269-428-3304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
23C0001131Medicare Oscar/Certification