Healthcare Provider Details

I. General information

NPI: 1609800614
Provider Name (Legal Business Name): GREAT LAKES SPECIALTY HOSPITAL - OAK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE 5TH FLOOR
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

4714 GETTYSBURG RD LEGAL DEPT
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 231-777-6202
  • Fax: 231-777-6207
Mailing address:
  • Phone: 717-972-1100
  • Fax: 717-975-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number610052
License Number StateMI

VIII. Authorized Official

Name: MR. MICHAEL TARVIN
Title or Position: VICE PRESIDENT
Credential:
Phone: 717-972-1100