Provider Demographics
NPI:1972795334
Name:GREAT LAKES PLASTIC SURGERY CENTER
Entity Type:Organization
Organization Name:GREAT LAKES PLASTIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRANCIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-0180
Mailing Address - Street 1:5085 ANNA DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9691
Mailing Address - Country:US
Mailing Address - Phone:231-935-0180
Mailing Address - Fax:231-935-0099
Practice Address - Street 1:5085 ANNA DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9691
Practice Address - Country:US
Practice Address - Phone:231-935-0180
Practice Address - Fax:231-935-0099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301067433OtherSTATE LICENSE
MI2402810821OtherBLUE CROSS BLUE SHIELD MI
MI1285614032OtherNPI
MI4156180Medicaid
MI4704192319OtherSTATE LICENSE
MI1437139318OtherNPI
MI3495242Medicaid
MI5008762590OtherBLUE CROSS BLUE SHIELD MI
MI0M67020Medicare UPIN
MI2402810821OtherBLUE CROSS BLUE SHIELD MI
MI0M91950Medicare UPIN