Provider Demographics
NPI:1881855328
Name:GREAT LAKES HEALTHCARE, PLLC
Entity Type:Organization
Organization Name:GREAT LAKES HEALTHCARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DAMBACHER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-378-4900
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:YALE
Mailing Address - State:MI
Mailing Address - Zip Code:48097-0129
Mailing Address - Country:US
Mailing Address - Phone:810-378-4900
Mailing Address - Fax:810-378-4905
Practice Address - Street 1:251 E PECK RD
Practice Address - Street 2:
Practice Address - City:PECK
Practice Address - State:MI
Practice Address - Zip Code:48466-9589
Practice Address - Country:US
Practice Address - Phone:810-378-4900
Practice Address - Fax:810-378-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114469926Medicaid
MI5670042OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI08-0G61059-0OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI5741038Medicare PIN
MI5670042OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIE26231Medicare UPIN