Provider Demographics
NPI:1225079932
Name:GREAT LAKES PODIATRY PLLC
Entity Type:Organization
Organization Name:GREAT LAKES PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVEILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-786-5106
Mailing Address - Street 1:126 S 25TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1364
Mailing Address - Country:US
Mailing Address - Phone:906-786-2385
Mailing Address - Fax:906-789-4445
Practice Address - Street 1:126 S 25TH ST
Practice Address - Street 2:SUITE A
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:906-789-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4729159Medicaid
MI0P07610Medicare ID - Type Unspecified
MI5347440002Medicare NSC
MI4729159Medicaid