Basic Information
| Provider Information | |||||||||
| NPI: | 1881855328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES HEALTHCARE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 129 | ||||||||
| Address2: | |||||||||
| City: | YALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480970129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103784900 | ||||||||
| FaxNumber: | 8103784905 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 E PECK RD | ||||||||
| Address2: | |||||||||
| City: | PECK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484669589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103784900 | ||||||||
| FaxNumber: | 8103784905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 11/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | DAMBACHER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8103784900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101008768 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 114469926 | 05 | MI | MEDICAID | 5670042 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER | 08-0G61059-0 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER |