Healthcare Provider Details

I. General information

NPI: 1811094295
Provider Name (Legal Business Name): GREAT LAKES MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E. MAIN STREET
EDMORE MI
48829
US

IV. Provider business mailing address

1021 E. MAIN STREET
EDMORE MI
48829
US

V. Phone/Fax

Practice location:
  • Phone: 989-427-5320
  • Fax: 989-427-8220
Mailing address:
  • Phone: 989-427-5320
  • Fax: 989-427-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: PRAKASH SARVEPALLI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 989-427-5320