Healthcare Provider Details

I. General information

NPI: 1851597140
Provider Name (Legal Business Name): GREAT LAKES VASCULAR CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 ELECTRIC AVE SUITE C
PORT HURON MI
48060-6588
US

IV. Provider business mailing address

2603 ELECTRIC AVE SUITE C
PORT HURON MI
48060-6588
US

V. Phone/Fax

Practice location:
  • Phone: 810-984-8470
  • Fax: 810-966-3025
Mailing address:
  • Phone: 810-984-8470
  • Fax: 810-966-3025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301403638
License Number StateMI

VIII. Authorized Official

Name: DR. SAQID HUSSAIN
Title or Position: OWNER
Credential: M.D.
Phone: 810-985-1884