Healthcare Provider Details

I. General information

NPI: 1427155357
Provider Name (Legal Business Name): GREAT LAKES CANCER MGMT SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11051 HALL RD STE 120
UTICA MI
48317-5735
US

IV. Provider business mailing address

11051 HALL RD STE 120
UTICA MI
48317-5735
US

V. Phone/Fax

Practice location:
  • Phone: 586-991-0700
  • Fax: 586-991-0701
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number4301056352
License Number StateMI

VIII. Authorized Official

Name: ROXANNE CLARK
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 313-884-5524