Provider Demographics
NPI:1568420388
Name:GREAT LAKES SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:GREAT LAKES SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:METZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-223-9925
Mailing Address - Street 1:26051 LAHSER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2601
Mailing Address - Country:US
Mailing Address - Phone:248-223-9925
Mailing Address - Fax:248-223-9957
Practice Address - Street 1:26051 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-2601
Practice Address - Country:US
Practice Address - Phone:248-223-9925
Practice Address - Fax:248-223-9957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QA1903X261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI490F328640OtherBLUE CROSS SECONDARY
MI17228OtherMCARE
MI40332OtherBLUE CROSS PRIMARY
MI40332OtherBLUE CROSS PRIMARY