Provider Demographics
NPI:1922421387
Name:GREAT LAKES BAY HEALTH CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES BAY HEALTH CENTERS
Other - Org Name:GREAT LAKES BAY HEALTH CENTERS INTEGRATED CARE THUMB AREA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALONSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-759-6464
Mailing Address - Street 1:501 LAPEER AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1208
Mailing Address - Country:US
Mailing Address - Phone:989-759-6464
Mailing Address - Fax:989-399-8233
Practice Address - Street 1:1375 R DALE WERTZ DR
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1365
Practice Address - Country:US
Practice Address - Phone:989-623-0137
Practice Address - Fax:989-921-4977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231024Medicare Oscar/Certification