Provider Demographics
NPI:1508955816
Name:GREAT LAKES MEDICAL CENTER PC
Entity Type:Organization
Organization Name:GREAT LAKES MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:H
Authorized Official - Last Name:STARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-598-8880
Mailing Address - Street 1:33006 7 MILE RD
Mailing Address - Street 2:#176
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1358
Mailing Address - Country:US
Mailing Address - Phone:586-427-4453
Mailing Address - Fax:586-427-5573
Practice Address - Street 1:27500 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4586
Practice Address - Country:US
Practice Address - Phone:586-427-4453
Practice Address - Fax:586-427-5573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherEIN