Healthcare Provider Details

I. General information

NPI: 1043728553
Provider Name (Legal Business Name): GREAT LAKES PODIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S 25TH ST STE A
ESCANABA MI
49829-1364
US

IV. Provider business mailing address

W4042 LAKE MARY DR S
VULCAN MI
49892-8452
US

V. Phone/Fax

Practice location:
  • Phone: 906-786-2385
  • Fax: 877-276-3960
Mailing address:
  • Phone: 906-280-5396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5901001228
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number5901001228
License Number StateMI

VIII. Authorized Official

Name: DENNIS W LEVEILLE
Title or Position: OWNER/PODIATRIST
Credential: DPM
Phone: 906-786-2385