Provider Demographics
NPI:1780691899
Name:GREAT LAKES GASTROENTEROLOGY PLLC
Entity type:Organization
Organization Name:GREAT LAKES GASTROENTEROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-408-1100
Mailing Address - Street 1:3903 HOLLYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9149
Mailing Address - Country:US
Mailing Address - Phone:269-408-1100
Mailing Address - Fax:269-408-1329
Practice Address - Street 1:3903 HOLLYWOOD RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9149
Practice Address - Country:US
Practice Address - Phone:269-408-1100
Practice Address - Fax:269-408-1329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M95110Medicare ID - Type UnspecifiedGROUP NUMBER