Provider Demographics
NPI:1598742801
Name:GREAT LAKES PHYSICIANS LLC
Entity Type:Organization
Organization Name:GREAT LAKES PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGHAFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-702-0360
Mailing Address - Street 1:6681 RIDGE ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5713
Mailing Address - Country:US
Mailing Address - Phone:216-398-0863
Mailing Address - Fax:216-351-3619
Practice Address - Street 1:6681 RIDGE ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5713
Practice Address - Country:US
Practice Address - Phone:216-398-0863
Practice Address - Fax:216-351-3619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2518798Medicaid
OH2518798Medicaid
OH9347791Medicare PIN