Provider Demographics
NPI:1679845671
Name:GREAT LAKES MEDICAL PC
Entity Type:Organization
Organization Name:GREAT LAKES MEDICAL PC
Other - Org Name:GLADWIN URGENT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:MACAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-516-4317
Mailing Address - Street 1:1277 E CEDAR AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-7004
Mailing Address - Country:US
Mailing Address - Phone:989-426-1100
Mailing Address - Fax:989-426-1400
Practice Address - Street 1:1277 E CEDAR AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-7004
Practice Address - Country:US
Practice Address - Phone:989-426-1100
Practice Address - Fax:989-426-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042308208D00000X
MI261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty