Provider Demographics
NPI:1437218609
Name:GREAT LAKES RADIATION MEDICINE PC
Entity Type:Organization
Organization Name:GREAT LAKES RADIATION MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:O
Authorized Official - Last Name:THIEME
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:906-228-9440
Mailing Address - Street 1:420 W MAGNETIC STREET
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-228-9440
Mailing Address - Fax:906-225-3772
Practice Address - Street 1:420 W MAGNETIC STREET
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-228-9440
Practice Address - Fax:906-225-3772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION85060Medicare ID - Type Unspecified