Healthcare Provider Details

I. General information

NPI: 1669472270
Provider Name (Legal Business Name): GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9615 KEILMAN ST
SAINT JOHN IN
46373-9406
US

IV. Provider business mailing address

9615 KEILMAN ST
SAINT JOHN IN
46373-9406
US

V. Phone/Fax

Practice location:
  • Phone: 219-365-0220
  • Fax: 219-365-0226
Mailing address:
  • Phone: 219-365-0220
  • Fax: 219-365-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001187A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02002102
License Number StateIN

VIII. Authorized Official

Name: KEITH R. PITCHFORD
Title or Position: PRESIDENT/CEO
Credential: DO
Phone: 219-365-0220