Provider Demographics
NPI:1912265547
Name:GREAT LAKES BAY HEALTH CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES BAY HEALTH CENTERS
Other - Org Name:GREAT LAKES BAY HEALTH CENTERS SHIAWASSEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERUM PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GALSONSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-759-6448
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 1:200 N CALEDONIA DR
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867
Practice Address - Country:US
Practice Address - Phone:989-729-4848
Practice Address - Fax:989-729-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231013Medicare Oscar/Certification