Provider Demographics
NPI:1548764376
Name:GREAT LAKES ORTHOPEDICS PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:GREAT LAKES ORTHOPEDICS PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:PITCHFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-365-0220
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2065
Mailing Address - Fax:
Practice Address - Street 1:9615 KEILMAN ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9406
Practice Address - Country:US
Practice Address - Phone:219-365-0220
Practice Address - Fax:219-365-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-19
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty