Provider Demographics
NPI:1740210517
Name:GREAT LAKES MEDICINE, PLC
Entity Type:Organization
Organization Name:GREAT LAKES MEDICINE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASHANT
Authorized Official - Middle Name:S
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-731-8400
Mailing Address - Street 1:1746 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5317
Mailing Address - Country:US
Mailing Address - Phone:586-731-8400
Mailing Address - Fax:586-731-8406
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:STE 340
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:586-731-8400
Practice Address - Fax:586-731-8406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X207R00000X
MI208M00000X208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDE1755OtherRR MEDICARE
MI0E03034OtherBCBS
MI0P24580Medicare Oscar/Certification