Provider Demographics
NPI:1952323453
Name:GREAT LAKES ORTHOPAEDIC CENTER, P.C.
Entity Type:Organization
Organization Name:GREAT LAKES ORTHOPAEDIC CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISSY
Authorized Official - Middle Name:
Authorized Official - Last Name:DURGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-929-5734
Mailing Address - Street 1:4045 W ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8965
Mailing Address - Country:US
Mailing Address - Phone:231-935-0900
Mailing Address - Fax:231-935-0308
Practice Address - Street 1:4045 W ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8965
Practice Address - Country:US
Practice Address - Phone:231-935-0900
Practice Address - Fax:231-935-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200B811700OtherBLUE CROSS BLUE SHIELD GROUP ID #
0M00980Medicare ID - Type Unspecified
MI200B811700OtherBLUE CROSS BLUE SHIELD GROUP ID #