Basic Information
| Provider Information | |||||||||
| NPI: | 1639591019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES GASTROENTEROLOGY RESEARCH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9485 MENTOR AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440604597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402051225 | ||||||||
| FaxNumber: | 4402051275 | ||||||||
| Practice Location | |||||||||
| Address1: | 9485 MENTOR AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440604597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402051225 | ||||||||
| FaxNumber: | 4402051275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2014 | ||||||||
| LastUpdateDate: | 01/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | NOWAK | ||||||||
| AuthorizedOfficialFirstName: | LEAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4402051225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1744R1102X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | Research Study |
No ID Information.