Provider Demographics
NPI:1891069605
Name:GREAT LAKES ANESTHESIA INDIANA AND MICHIGAN, PLLC
Entity Type:Organization
Organization Name:GREAT LAKES ANESTHESIA INDIANA AND MICHIGAN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BART
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-522-9922
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-0686
Mailing Address - Country:US
Mailing Address - Phone:574-522-9922
Mailing Address - Fax:574-522-9926
Practice Address - Street 1:916 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-2326
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:2012-02-27
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
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
MI0G50067OtherANTHEM
MI1891069605Medicaid
MI0G50066OtherANTHEM
MIDS9802OtherRAILROAD MEDICARE
MIDS9802OtherRAILROAD MEDICARE