Healthcare Provider Details

I. General information

NPI: 1972795334
Provider Name (Legal Business Name): GREAT LAKES PLASTIC SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5085 ANNA DR
TRAVERSE CITY MI
49684-9691
US

IV. Provider business mailing address

5085 ANNA DR
TRAVERSE CITY MI
49684-9691
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0180
  • Fax: 231-935-0099
Mailing address:
  • Phone: 231-935-0180
  • Fax: 231-935-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. CATHERINE S FRANCIS
Title or Position: MEDICAL BILLER
Credential:
Phone: 231-935-0180