Provider Demographics
NPI:1740603885
Name:UPPER GREAT LAKES FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:UPPER GREAT LAKES FAMILY HEALTH CENTER
Other - Org Name:LAKE LINDEN FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-483-1325
Mailing Address - Street 1:301 EXPLORER ST
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-2813
Mailing Address - Country:US
Mailing Address - Phone:906-481-8586
Mailing Address - Fax:906-483-1394
Practice Address - Street 1:945 NINTH STREET
Practice Address - Street 2:
Practice Address - City:LAKE LINDEN
Practice Address - State:MI
Practice Address - Zip Code:49945-1100
Practice Address - Country:US
Practice Address - Phone:906-483-1030
Practice Address - Fax:906-483-1270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-25
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231021Medicare Oscar/Certification