Provider Demographics
NPI:1114055662
Name:GREAT LAKES CARDIOVASCULAR & THORACIC SURGEONS
Entity Type:Organization
Organization Name:GREAT LAKES CARDIOVASCULAR & THORACIC SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EQUAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-441-1441
Mailing Address - Street 1:17000 HUBBARD DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4258
Mailing Address - Country:US
Mailing Address - Phone:313-441-1441
Mailing Address - Fax:313-441-2071
Practice Address - Street 1:17000 HUBBARD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4258
Practice Address - Country:US
Practice Address - Phone:313-441-1441
Practice Address - Fax:313-441-2071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty