Provider Demographics
NPI:1669472270
Name:GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PITCHFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-365-0220
Mailing Address - Street 1:9615 KEILMAN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9406
Mailing Address - Country:US
Mailing Address - Phone:219-365-0220
Mailing Address - Fax:219-365-0226
Practice Address - Street 1:9615 KEILMAN ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9406
Practice Address - Country:US
Practice Address - Phone:219-365-0220
Practice Address - Fax:219-365-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002102207X00000X
IN07001187A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDC2442OtherRAILROAD MEDICARE
IL90001186OtherBC/BS IL
INDC2442OtherRAILROAD MEDICARE
IL90001186OtherBC/BS IL