Provider Demographics
NPI:1720039977
Name:GREAT LAKES ANESTHESIA, P.C.
Entity Type:Organization
Organization Name:GREAT LAKES ANESTHESIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:574-522-9922
Mailing Address - Street 1:1004 PARKWAY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516
Mailing Address - Country:US
Mailing Address - Phone:574-522-9922
Mailing Address - Fax:574-522-9926
Practice Address - Street 1:1004 PARKWAY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516
Practice Address - Country:US
Practice Address - Phone:574-522-9922
Practice Address - Fax:574-522-9926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X
IN367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200250870Medicaid
INCB9080Medicare PIN
IN145420Medicare PIN