Healthcare Provider Details

I. General information

NPI: 1023342474
Provider Name (Legal Business Name): GREAT LAKES PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 PINETREE RD STE 102
LANSING MI
48911-4286
US

IV. Provider business mailing address

3400 PINETREE RD STE 102
LANSING MI
48911-4286
US

V. Phone/Fax

Practice location:
  • Phone: 517-887-3000
  • Fax:
Mailing address:
  • Phone: 517-887-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301063626
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301078945
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301086445
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301049233
License Number StateMI

VIII. Authorized Official

Name: MS. BETH ILEEN CHARLES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 517-887-3000