Provider Demographics
NPI:1609265941
Name:GREAT LAKES DIAGNOSTIC FACILITY LLC
Entity Type:Organization
Organization Name:GREAT LAKES DIAGNOSTIC FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAQAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-780-4415
Mailing Address - Street 1:3061 CHRISTY WAY
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2224
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:989-791-1392
Practice Address - Street 1:1525 W CARO RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9686
Practice Address - Country:US
Practice Address - Phone:989-672-2100
Practice Address - Fax:989-672-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059644207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty