Provider Demographics
NPI:1417126715
Name:GREAT LAKES PEDIATRICS
Entity Type:Organization
Organization Name:GREAT LAKES PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNDUS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUMMANI-ASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-427-1351
Mailing Address - Street 1:26000 HOOVER RD
Mailing Address - Street 2:103
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1167
Mailing Address - Country:US
Mailing Address - Phone:586-427-1351
Mailing Address - Fax:
Practice Address - Street 1:26000 HOOVER RD
Practice Address - Street 2:103
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1167
Practice Address - Country:US
Practice Address - Phone:586-427-1351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010739622080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4435267Medicaid