Healthcare Provider Details

I. General information

NPI: 1437218609
Provider Name (Legal Business Name): GREAT LAKES RADIATION MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W MAGNETIC STREET
MARQUETTE MI
49855
US

IV. Provider business mailing address

420 W MAGNETIC STREET
MARQUETTE MI
49855
US

V. Phone/Fax

Practice location:
  • Phone: 906-228-9440
  • Fax: 906-225-3772
Mailing address:
  • Phone: 906-228-9440
  • Fax: 906-225-3772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL O THIEME
Title or Position: PRESIDENT
Credential: DO
Phone: 906-228-9440