Provider Demographics
NPI:1912189457
Name:GREAT LAKES ALLERGY AND ASTHMA CENTER, P.C.
Entity Type:Organization
Organization Name:GREAT LAKES ALLERGY AND ASTHMA CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER; PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:MIKE
Authorized Official - Last Name:RANTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-253-0400
Mailing Address - Street 1:309 W 12TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-2885
Mailing Address - Country:US
Mailing Address - Phone:906-253-0400
Mailing Address - Fax:
Practice Address - Street 1:309 W 12TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2885
Practice Address - Country:US
Practice Address - Phone:906-253-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082835207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4609268Medicaid
MII06942Medicare UPIN
0N91630Medicare PIN