Provider Demographics
NPI:1407406911
Name:GREAT LAKES IMAGING S C
Entity Type:Organization
Organization Name:GREAT LAKES IMAGING S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCANLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-354-8724
Mailing Address - Street 1:13333 NORTHWEST FWY STE 540
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6166
Mailing Address - Country:US
Mailing Address - Phone:561-366-2002
Mailing Address - Fax:
Practice Address - Street 1:2330 UTAH AVE STE 200
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4817
Practice Address - Country:US
Practice Address - Phone:424-290-8004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty