Provider Demographics
NPI:1043728553
Name:GREAT LAKES PODIATRY PLLC
Entity Type:Organization
Organization Name:GREAT LAKES PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEVEILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:906-786-2385
Mailing Address - Street 1:W4042 LAKE MARY DR S
Mailing Address - Street 2:
Mailing Address - City:VULCAN
Mailing Address - State:MI
Mailing Address - Zip Code:49892-8452
Mailing Address - Country:US
Mailing Address - Phone:906-280-5396
Mailing Address - Fax:
Practice Address - Street 1:126 S 25TH ST STE A
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1364
Practice Address - Country:US
Practice Address - Phone:906-786-2385
Practice Address - Fax:906-563-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001228332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1982696209Medicaid
MI1225079932Medicaid