Healthcare Provider Details

I. General information

NPI: 1548570062
Provider Name (Legal Business Name): LAKES OBGYN SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 PRAIRIE ST STE 1700
NORTON SHORES MI
49444-7843
US

IV. Provider business mailing address

PO BOX 776982
CHICAGO IL
60677-6982
US

V. Phone/Fax

Practice location:
  • Phone: 231-672-7939
  • Fax:
Mailing address:
  • Phone: 800-494-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL GUSHO
Title or Position: CHIEF FINANCIAL OFFICE
Credential:
Phone: 734-398-0642