Provider Demographics
NPI:1598912750
Name:GREAT LAKES ANESTHESIA, PLC
Entity Type:Organization
Organization Name:GREAT LAKES ANESTHESIA, PLC
Other - Org Name:ANESTHESIA SERVICES ASSOCIATES, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:FULEIHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-787-7438
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:PO BOX 1123
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:800-242-1131
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:1221 PINE GROVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-989-3207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N50580Medicare PIN