Provider Demographics
NPI:1467696153
Name:GREAT LAKES IN-HOME CLINICIAN SERVICES INC
Entity Type:Organization
Organization Name:GREAT LAKES IN-HOME CLINICIAN SERVICES INC
Other - Org Name:ELITE MEDICAL SERVICES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAVITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SURYAVANSHI
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:810-245-9400
Mailing Address - Street 1:404 W NEPESSING ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2150
Mailing Address - Country:US
Mailing Address - Phone:810-664-7040
Mailing Address - Fax:810-245-9080
Practice Address - Street 1:124 S STATE RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1347
Practice Address - Country:US
Practice Address - Phone:810-664-7040
Practice Address - Fax:810-245-9080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1845Medicare PIN