Provider Demographics
NPI:1093245458
Name:GREAT LAKES SURGICAL SUITES, LLC
Entity Type:Organization
Organization Name:GREAT LAKES SURGICAL SUITES, LLC
Other - Org Name:GREAT LAKES SURGICAL SUITES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-800-2017
Mailing Address - Street 1:14201 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2916
Mailing Address - Country:US
Mailing Address - Phone:219-513-9955
Mailing Address - Fax:219-513-9373
Practice Address - Street 1:9200 CALUMET AVE STE N500
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2849
Practice Address - Country:US
Practice Address - Phone:219-513-9955
Practice Address - Fax:219-513-9373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical