Provider Demographics
NPI:1942548946
Name:GREAT LAKES MEDICAL PC
Entity Type:Organization
Organization Name:GREAT LAKES MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MACAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:517-449-2452
Mailing Address - Street 1:611 COURT ST
Mailing Address - Street 2:PO BOX 428
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-9390
Mailing Address - Country:US
Mailing Address - Phone:989-773-9700
Mailing Address - Fax:
Practice Address - Street 1:1111 S MISSION ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3944
Practice Address - Country:US
Practice Address - Phone:989-773-9700
Practice Address - Fax:989-779-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI04411G261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI04411GMedicare Oscar/Certification