Provider Demographics
NPI:1679973408
Name:GREAT LAKES MEDICAL EQUIPMENT GROUP
Entity Type:Organization
Organization Name:GREAT LAKES MEDICAL EQUIPMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SEHRISH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHURRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-892-7722
Mailing Address - Street 1:6940 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48722-9760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6940 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9760
Practice Address - Country:US
Practice Address - Phone:989-892-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies