Basic Information
| Provider Information | |||||||||
| NPI: | 1396295721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPPER GREAT LAKES FAMILY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 EXPLORER ST | ||||||||
| Address2: | |||||||||
| City: | GWINN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498412813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064818586 | ||||||||
| FaxNumber: | 9064831394 | ||||||||
| Practice Location | |||||||||
| Address1: | 56720 CALUMET AVE | ||||||||
| Address2: | |||||||||
| City: | CALUMET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499131967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831177 | ||||||||
| FaxNumber: | 9064831188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | SIMILA | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9064831325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.