Provider Demographics
NPI:1285822387
Name:GREAT LAKES DIGESTIVE HEALTH ASSC PC
Entity Type:Organization
Organization Name:GREAT LAKES DIGESTIVE HEALTH ASSC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:STONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-487-2391
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:STE M40
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2278
Mailing Address - Country:US
Mailing Address - Phone:231-487-2391
Mailing Address - Fax:231-487-6513
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:STE M40
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2278
Practice Address - Country:US
Practice Address - Phone:231-487-2391
Practice Address - Fax:231-487-6513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091670207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285822387Medicaid
1285822387Medicare PIN
MI1285822387Medicaid