Healthcare Provider Details

I. General information

NPI: 1720039977
Provider Name (Legal Business Name): GREAT LAKES ANESTHESIA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E BEARDSLEY AVE STE 209
ELKHART IN
46514-3371
US

IV. Provider business mailing address

PO BOX 2147
ELKHART IN
46515-2147
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-9922
  • Fax: 574-522-9926
Mailing address:
  • Phone: 574-522-9922
  • Fax: 574-522-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateIN

VIII. Authorized Official

Name: MR. SETH CLAXTON
Title or Position: CEO
Credential: CRNA
Phone: 574-522-9922