Healthcare Provider Details

I. General information

NPI: 1952323453
Provider Name (Legal Business Name): GREAT LAKES ORTHOPAEDIC CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 W ROYAL DR
TRAVERSE CITY MI
49684-8965
US

IV. Provider business mailing address

4045 W ROYAL DR
TRAVERSE CITY MI
49684-8965
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0900
  • Fax: 231-935-0308
Mailing address:
  • Phone: 231-935-0900
  • Fax: 231-935-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: CHRISSY DURGA
Title or Position: ADMINISTRATOR
Credential:
Phone: 231-929-5734