Provider Demographics
NPI:1982702973
Name:GREAT LAKES CANCER MGMT SPECIALISTS
Entity Type:Organization
Organization Name:GREAT LAKES CANCER MGMT SPECIALISTS
Other - Org Name:DANIEL J LEHMAN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FIN.OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MPA,FAAMA
Authorized Official - Phone:313-884-5524
Mailing Address - Street 1:19229 MACK AVE STE 24
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19229 MACK AVE STE 24
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2857
Practice Address - Country:US
Practice Address - Phone:313-884-5522
Practice Address - Fax:313-884-5737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406109332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
2367161OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI2752283Medicaid
OH26126004Medicare ID - Type Unspecified