Provider Demographics
NPI:1164591053
Name:GREAT LAKES PHYSICIANS PC
Entity Type:Organization
Organization Name:GREAT LAKES PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAYSHREE
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-591-7666
Mailing Address - Street 1:36180 FIVE MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154
Mailing Address - Country:US
Mailing Address - Phone:734-591-7666
Mailing Address - Fax:734-591-2426
Practice Address - Street 1:36180 FIVE MILE ROAD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154
Practice Address - Country:US
Practice Address - Phone:734-591-7666
Practice Address - Fax:734-591-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3323140Medicaid
MI3323140Medicaid
MI0P38630Medicare ID - Type Unspecified