Provider Demographics
NPI:1639591019
Name:GREAT LAKES GASTROENTEROLOGY RESEARCH
Entity Type:Organization
Organization Name:GREAT LAKES GASTROENTEROLOGY RESEARCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NOWAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-205-1225
Mailing Address - Street 1:9485 MENTOR AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4597
Mailing Address - Country:US
Mailing Address - Phone:440-205-1225
Mailing Address - Fax:440-205-1275
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4597
Practice Address - Country:US
Practice Address - Phone:440-205-1225
Practice Address - Fax:440-205-1275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-20
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744R1102XOther Service ProvidersSpecialistResearch StudyGroup - Single Specialty