Healthcare Provider Details

I. General information

NPI: 1891069605
Provider Name (Legal Business Name): GREAT LAKES ANESTHESIA INDIANA AND MICHIGAN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 MYRTLE ST
STURGIS MI
49091-2326
US

IV. Provider business mailing address

PO BOX 686
INDIANAPOLIS IN
46206-0686
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-9922
  • Fax: 574-522-9926
Mailing address:
  • Phone: 574-522-9922
  • Fax: 574-522-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: ROBERT BART POWERS
Title or Position: OWNER/BOARD MEMBER
Credential: D.O.
Phone: 574-522-9922