Provider Demographics
NPI:1023498219
Name:GREAT LAKES AMBULATORY SURGERY CENTER
Entity type:Organization
Organization Name:GREAT LAKES AMBULATORY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:AZMY
Authorized Official - Last Name:MIKHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-306-2358
Mailing Address - Street 1:2760 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9111
Mailing Address - Country:US
Mailing Address - Phone:440-306-2358
Mailing Address - Fax:440-306-2359
Practice Address - Street 1:9002 MENTOR AVE STE B
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6302
Practice Address - Country:US
Practice Address - Phone:440-283-0244
Practice Address - Fax:440-283-0247
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES PAIN MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-03
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-075570261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2124534Medicaid
OHMI 4088362Medicare PIN
OHH02372Medicare UPIN