Provider Demographics
NPI:1811094295
Name:GREAT LAKES MEDICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:GREAT LAKES MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRAKASH
Authorized Official - Middle Name:
Authorized Official - Last Name:SARVEPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-427-5320
Mailing Address - Street 1:1021 E. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:EDMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48829
Mailing Address - Country:US
Mailing Address - Phone:989-427-5320
Mailing Address - Fax:989-427-8220
Practice Address - Street 1:1021 E. MAIN STREET
Practice Address - Street 2:
Practice Address - City:EDMORE
Practice Address - State:MI
Practice Address - Zip Code:48829
Practice Address - Country:US
Practice Address - Phone:989-427-5320
Practice Address - Fax:989-427-8220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X, 363A00000X, 363L00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E91083OtherBCBSM
MI0E91083OtherBCBSM