Provider Demographics
NPI:1326152091
Name:GREAT LAKES MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:GREAT LAKES MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BRUELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-872-5343
Mailing Address - Street 1:1021 SANDUSKY ST
Mailing Address - Street 2:STE C
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551
Mailing Address - Country:US
Mailing Address - Phone:419-872-5343
Mailing Address - Fax:419-872-7465
Practice Address - Street 1:1021 SANDUSKY ST
Practice Address - Street 2:STE C
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551
Practice Address - Country:US
Practice Address - Phone:419-872-5343
Practice Address - Fax:419-872-7465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGR9353491Medicare UPIN