Provider Demographics
NPI:1346283116
Name:GREAT LAKES CARDIOTHORACIC & VASCULAR SURGERY PLLC
Entity Type:Organization
Organization Name:GREAT LAKES CARDIOTHORACIC & VASCULAR SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:VAZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-487-9090
Mailing Address - Street 1:2390 MITCHELL PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8965
Mailing Address - Country:US
Mailing Address - Phone:231-487-9090
Mailing Address - Fax:231-487-9191
Practice Address - Street 1:2390 MITCHELL PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8965
Practice Address - Country:US
Practice Address - Phone:231-487-9090
Practice Address - Fax:231-487-9191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI780001998OtherRR MEDICARE
MI0N57190Medicare PIN