Provider Demographics
NPI:1649474057
Name:GREAT LAKES BAY HEALTH CENTERS
Entity type:Organization
Organization Name:GREAT LAKES BAY HEALTH CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALONSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-759-6464
Mailing Address - Street 1:501 LAPEER
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1208
Mailing Address - Country:US
Mailing Address - Phone:989-759-6464
Mailing Address - Fax:989-399-8233
Practice Address - Street 1:318 S BRIDGE ST STE B
Practice Address - Street 2:
Practice Address - City:BELDING
Practice Address - State:MI
Practice Address - Zip Code:48809-1764
Practice Address - Country:US
Practice Address - Phone:616-794-5221
Practice Address - Fax:616-794-5227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G36111Other0G36111 MEDICARE BILL PAY TO
MI231810Medicare Oscar/Certification
MI0G36111Other0G36111 MEDICARE BILL PAY TO