MEDICARE: GL MOMENTUM PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1003505363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GL MOMENTUM PLLC

Provider Business Mailing Address
First Line	:	32905 W 12 MILE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-3342
Country	:	US
Telephone Number	:	313-759-7102
Fax Number	:	248-278-1336

Provider Business Practice Location Address
First Line	:	395 S SHORE DR
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-5466
Country	:	US
Telephone Number	:	947-217-3212
Fax Number	:	877-694-3717

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	OKSANA LIDKE
Credential	:
Telephone Number	:	231-246-5252

Provider Enumeration Date	:	05/03/2023
Last Update Date	:	04/08/2026

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