Healthcare Provider Details

I. General information

NPI: 1689212581
Provider Name (Legal Business Name): GREAT LAKES EMERGENCY PHYSICIANS MEDICAL GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND AVE
CHICAGO IL
60649-3954
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7500
  • Fax:
Mailing address:
  • Phone: 844-474-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN PETER MARON
Title or Position: MD
Credential: MD
Phone: 925-225-5837