Provider Demographics
NPI:1366478026
Name:GREAT LAKES OBSTETRIC GYNECOLOGICAL SPECIALISTS PLC
Entity Type:Organization
Organization Name:GREAT LAKES OBSTETRIC GYNECOLOGICAL SPECIALISTS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KARNES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-773-9048
Mailing Address - Street 1:1775 WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-2459
Mailing Address - Country:US
Mailing Address - Phone:231-773-9048
Mailing Address - Fax:231-777-1218
Practice Address - Street 1:1775 WELLS AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-2459
Practice Address - Country:US
Practice Address - Phone:231-773-9048
Practice Address - Fax:231-777-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK008760174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI433625011Medicaid
MI461890011Medicaid
MI433624011Medicaid
MI483147511Medicaid
MIH13079Medicare UPIN
MI0N33710005Medicare ID - Type Unspecified
MI0N33710001Medicare ID - Type Unspecified
MIE26381Medicare UPIN
MI461890011Medicaid
MI0N33710004Medicare ID - Type Unspecified
MI483147511Medicaid
MI433625011Medicaid