MEDICARE: GREAT LAKES GYNECOLOGY & AESTHETICS INC, PC

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	207VG0400X	Gynecology Physician	207VG0400X	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366589996
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES GYNECOLOGY & AESTHETICS INC, PC

Provider Business Mailing Address
First Line	:	126 SOUTH 25TH STREET
Second Line	:	SUITE B
City	:	ESCANABA
State	:	MI
Zip	:	49829
Country	:	US
Telephone Number	:	906-233-9500
Fax Number	:	906-233-9925

Provider Business Practice Location Address
First Line	:	126 S 25TH ST
Second Line	:	SUITE B
City	:	ESCANABA
State	:	MI
Zip	:	49829-1364
Country	:	US
Telephone Number	:	906-233-9500
Fax Number	:	906-233-9925

Authorized Official
Title or Position	:	PHYSICIAN-SURGEON
Name	:	DR. DAVID LUIS HAMACHER
Credential	:	MD,FACOG
Telephone Number	:	906-233-9500

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	09/28/2009

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