Basic Information
| Provider Information | |||||||||
| NPI: | 1740210517 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES MEDICINE, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1746 MOMENTUM PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867318400 | ||||||||
| FaxNumber: | 5867318406 | ||||||||
| Practice Location | |||||||||
| Address1: | 50505 SCHOENHERR RD | ||||||||
| Address2: | STE 340 | ||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483153140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867318400 | ||||||||
| FaxNumber: | 5867318406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 11/05/2012 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | PRASHANT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5867318400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 207R00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 208M00000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | DE1755 | 01 | MI | RR MEDICARE | OTHER | 0E03034 | 01 | MI | BCBS | OTHER |