Provider Demographics
NPI:1518905264
Name:GREAT LAKES FAMILY HEALTH CENTER PC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RODAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEDICATORIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-790-0100
Mailing Address - Street 1:3424 DAVENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3365
Mailing Address - Country:US
Mailing Address - Phone:989-790-0100
Mailing Address - Fax:989-790-0241
Practice Address - Street 1:3424 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3365
Practice Address - Country:US
Practice Address - Phone:989-790-0100
Practice Address - Fax:989-790-0241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N73640Medicare PIN