Provider Demographics
NPI:1205911047
Name:GREAT LAKES HEART & VASCULAR INSTITUTE, P.C.
Entity type:Organization
Organization Name:GREAT LAKES HEART & VASCULAR INSTITUTE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:POW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-985-1000
Mailing Address - Street 1:3950 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9151
Mailing Address - Country:US
Mailing Address - Phone:269-985-1000
Mailing Address - Fax:269-983-1627
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9151
Practice Address - Country:US
Practice Address - Phone:269-985-1000
Practice Address - Fax:269-983-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITP054928207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4176414Medicaid
MI4176450Medicaid
MI3444708Medicaid
MI4718520Medicaid
MI4751365Medicaid
MI4176497Medicaid
MI4176450Medicaid
MIN12620Medicare PIN
MI4176497Medicaid
MIB87153Medicare UPIN
MI4176497Medicaid