Provider Demographics
NPI:1851597140
Name:GREAT LAKES VASCULAR CLINIC PC
Entity Type:Organization
Organization Name:GREAT LAKES VASCULAR CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAQID
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-985-1884
Mailing Address - Street 1:2603 ELECTRIC AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6588
Mailing Address - Country:US
Mailing Address - Phone:810-984-8470
Mailing Address - Fax:810-966-3025
Practice Address - Street 1:2603 ELECTRIC AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6588
Practice Address - Country:US
Practice Address - Phone:810-984-8470
Practice Address - Fax:810-966-3025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43014036382086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA76898Medicare UPIN
MIE56406Medicare UPIN