Provider Demographics
NPI:1245318278
Name:GREAT LAKES ORTHOPEDIC LABS, INC
Entity type:Organization
Organization Name:GREAT LAKES ORTHOPEDIC LABS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:DALEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:716-893-4116
Mailing Address - Street 1:1031 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1014
Mailing Address - Country:US
Mailing Address - Phone:716-893-4116
Mailing Address - Fax:716-897-2110
Practice Address - Street 1:1031 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1014
Practice Address - Country:US
Practice Address - Phone:716-893-4116
Practice Address - Fax:716-897-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00011212601OtherUNIVERA HEALTHCARE
NY000551033001OtherBLUE CROSS & BLUE SHIELD
NY16146OtherMOLINA HEALTHCARE
NY040401000151OtherFIDELIS CARE NEW YORK
NY8207649OtherINDEPENDENT HEALTH ASSOCI
NY0468010001Medicare ID - Type Unspecified