Healthcare Provider Details

I. General information

NPI: 1508955816
Provider Name (Legal Business Name): GREAT LAKES MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27500 HOOVER RD
WARREN MI
48093-4586
US

IV. Provider business mailing address

33006 7 MILE RD #176
LIVONIA MI
48152-1358
US

V. Phone/Fax

Practice location:
  • Phone: 586-427-4453
  • Fax: 586-427-5573
Mailing address:
  • Phone: 586-427-4453
  • Fax: 586-427-5573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MS. LINDA H. STARR
Title or Position: DIRECTOR
Credential:
Phone: 317-598-8880