Healthcare Provider Details

I. General information

NPI: 1982881025
Provider Name (Legal Business Name): GREAT LAKES FAMILY MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 E DAVISON ST
DETROIT MI
48212-1744
US

IV. Provider business mailing address

4420 E DAVISON ST
DETROIT MI
48212-1744
US

V. Phone/Fax

Practice location:
  • Phone: 313-369-1500
  • Fax: 313-369-1205
Mailing address:
  • Phone: 313-369-1500
  • Fax: 313-369-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AMITABH PAHARIA
Title or Position: OWNER
Credential: MD
Phone: 313-369-1500