Provider Demographics
NPI:1750727129
Name:GREAT LAKES MEDICAL, P,C,
Entity type:Organization
Organization Name:GREAT LAKES MEDICAL, P,C,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MACAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-449-2452
Mailing Address - Street 1:1277 E CEDAR AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-7004
Mailing Address - Country:US
Mailing Address - Phone:989-426-1100
Mailing Address - Fax:
Practice Address - Street 1:1277 E CEDAR AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-7004
Practice Address - Country:US
Practice Address - Phone:989-426-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI04411G261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI04411GOtherSTATE OF MICHIGAN ID
238926Medicare Oscar/Certification