Healthcare Provider Details

I. General information

NPI: 1609265941
Provider Name (Legal Business Name): GREAT LAKES DIAGNOSTIC FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W CARO RD
CARO MI
48723-9686
US

IV. Provider business mailing address

3061 CHRISTY WAY
SAGINAW MI
48603-2224
US

V. Phone/Fax

Practice location:
  • Phone: 989-672-2100
  • Fax: 989-672-2120
Mailing address:
  • Phone: 989-791-2455
  • Fax: 989-791-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301059644
License Number StateMI

VIII. Authorized Official

Name: WAQAR MIAN
Title or Position: OWNER
Credential:
Phone: 989-780-4415