Basic Information
| Provider Information | |||||||||
| NPI: | 1598737769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES FAMILY MEDICAL CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28801 PLYMOUTH RD | ||||||||
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| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481502385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342662780 | ||||||||
| FaxNumber: | 7344669615 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 E DAVISON ST | ||||||||
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| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482121744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133691500 | ||||||||
| FaxNumber: | 3133691205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHIRVASTAVA | ||||||||
| AuthorizedOfficialFirstName: | ARUNIMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7342662780 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.