Healthcare Provider Details

I. General information

NPI: 1003273129
Provider Name (Legal Business Name): GREAT LAKES SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2848 NILES RD SUITE B
SAINT JOSEPH MI
49085-3352
US

IV. Provider business mailing address

2848 NILES RD SUITE B
SAINT JOSEPH MI
49085-3352
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-3304
  • Fax:
Mailing address:
  • Phone: 269-428-3304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID N. BROWN
Title or Position: MANAGER MEMBER
Credential: M.D.
Phone: 269-428-3300